EuroTimes Vol. 21 - Issue 2

SPECIAL FOCUS CATARACT & REFRACTIVE LENS CORNEA

TOPOGRAPHY-GUIDED CROSSLINKING MAY OFFER SIGNIFICANT ADVANTAGES February 2016 | Vol 21 Issue 2

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RESIDENT’S DIARY

PERFORMING SOLO VITRECTOMY: A TEST OF BODY AND MIND

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Conor Ward Senior Designer Janice Robb Designer Lara Fitzgibbon Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Pippa Wysong Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland.

No part of this publication may be reproduced without the permission of the managing editor.

Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.

ESCRS EuroTimes is not responsible for statements made by any contributor.

These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes.

ISSN 1393-8983

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS CATARACT & REFRACTIVE LENS 4 Cover Story: The new

wave of multifocal and extended depth of focus IOLs 8 Accommodative IOLs – the emerging presbyopia solution 9 ‘The latest generation lenses provide excellent quantity and quality of vision’ 10 Sharp increase in the rate of late IOL dislocations over the last decade

FEATURES CATARACT & REFRACTIVE 12 ‘Consideration should 13

be given to widespread adoption of ISBCS’ ‘Chlorhexidine appears to be as effective as povidone-iodine for preoperative antisepsis protocol’

14 Obituary: Prof Albert

Galand, his huge impact on ophthalmology

P.26

15 Topography-guided

individualised crosslinking shows potential 16 Stronger evidence needed to determine epi-on CXL efficacy 18 Endothelial keratoplasty innovations: hemi-DMEK and DMET 20 PACK-CXL showing promise for challenges of corneal infection treatment

GLAUCOMA 21 ‘Trabecular bypass

implant can provide patients with long-term IOP reductions’

22 Critical analysis of

perimetry results key to determining progression rate

RETINA 23 Research underscores

need for detection of potentially toxic dosing

24 Kreissig Lecture:

‘A logical approach to retinal detachment’

26 Software application

P.42 As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2014 and 31 December 2014 is 42,957.

CORNEA

enables efficient quantification of retinal vessel properties

OCULAR 27 Growing concern over antibiotic resistance

PAEDIATRIC OPHTHALMOLOGY 28 ‘Femto-assisted

capsulotomies safe and effective in paediatric cataracts’ 29 Clear lens exchange – PCO and refractive changes are challenges

REGULARS 31 Innovation 32 Research 35 Resident’s Diary 37 ESCRS News 38 ESASO Update 39 JCRS Highlights 40 Industry News 41 Ophthalmologica Update 42 Review 44 Calendar

Included with this issue...

20-Year Anniversary: 1996–2016, and Laboratoires Théa supplement

EUROTIMES | FEBRUARY 2016

2

EDITORIAL A WORD FROM IOANNIS G PALLIKARIS MD, PhD

HUGE ADVANCEMENTS Originally conceived as a conference dedicated to refractive surgery, the ESCRS Winter Meeting has evolved over the last 20 years

T

he 20th ESCRS Winter Meeting in Athens, Greece You should also walk around Pláka, the old historical is being held in conjunction with the 30th Meeting neighbourhood of Athens clustered around the northern and of the Hellenic Society of Intraocular Implant and eastern slopes of the Acropolis, incorporating labyrinthine Refractive Surgery (HSIOIRS). This 20th ESCRS streets and neoclassical architecture. meeting is the third time the society has joined a As I have noted before, although scientific and technological meeting in Athens with HSIOIRS – the first taking progress is very important, we must never lose sight of the place in 1999 and the second in 2007. founding principles of the great philosophers and inventors of The first ESCRS Winter Meeting was held in Madrid ancient times who have much to teach us about the key values on 31 January 1997. The meeting hosted fewer than 200 that spur genuine innovation. delegates and two exhibition companies. There have been huge For our readers not making the trip to Athens this month, this advancements since then, both in the field of ophthalmology issue of EuroTimes has many interesting articles and reports. and the ESCRS. We expect over 1,000 ophthalmologists at this The cover story on new lenses for presbyopia correction reviews year’s meeting in Athens. the many lenses available on the market, and the evaluation Originally conceived as a conference dedicated to refractive criteria which are the keys to understanding the real function of surgery, the Winter Meeting has evolved over the last the these lenses and in particular 20 years. The didactic courses on refractive and cataract the final effect in vision quality.

There have been huge surgery and cornea are the centerpiece of the congress.

In addition there are reports on Along with Cornea Day, main symposia, wetlabs, longer follow-up on crosslinking advancements since free papers and an exciting Young Ophthalmologists and iStent® trabecular bypass, then, both in the field of Programme ensure there is a diversified programme and an article on “Emmetropia: ophthalmology and the available to all delegates. Meanwhile, an extensive The Perfect Imperfection”.

ESCRS. We expect over 1,000 industry exhibition highlights the enormous innovations This is a subject very close to in technology available to surgeons in our field. my heart. As I point out in the ophthalmologists at this Main symposia on key topics include ‘Explantations article, the very definition of the year’s meeting in Athens of Ocular Implants’, ‘Untold Secrets in Refractive term “emmetropia” may have to Surgery’ and ‘IOL Solutions for Posterior Capsular change, in light of the increasing Tears’. I would also urge delegates to attend the HSIORS understanding of the complex symposium and the Live Surgery session organised by our hosts. interaction between the static and dynamic components of For those of you who may decide to stay on in Athens after the human optical system and their subtler impacts on vision. the meeting, you can look forward to a treasure trove of sights I hope you enjoy this issue of EuroTimes. and experiences. Visit the iconic Parthenon, which crowns the Acropolis and draws the eye from vantage points all over Athens. It is the image of the city that you will never forget and you will take away memories of an unforgettable experience after you visit the most important surviving building of classical Greece.

Within walking distance from the conference centre, there are many important museums, like the Benaki Museum, The Ioannis G Pallikaris was President of the ESCRS from 2006-2007 Museum of Cycladic Art and Ethniki Pinakothiki Museum.

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Peter Barry (Ireland), Roberto Bellucci (Italy), Béatrice Cochener (France), Hiroko Bissen-Miyajima (Japan), John Chang (China), Alaa El Danasoury (Saudi Arabia), Oliver Findl (Austria), I Howard Fine (USA), Jack Holladay (USA) , Soosan Jacob (India), Vikentia Katsanevaki (Greece), Anastasios Konstas (Greece), Dennis Lam (Hong Kong), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Thomas Neuhann (Germany), Rudy Nuijts (The Netherlands), Gisbert Richard (Germany), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Emrullah Tasindi (Turkey), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany)

EUROTIMES | FEBRUARY 2016

PROGRESSIVE VISION WITHIN F ULL ACCO MMO D ATI VE RAN GE

PROGRESSIVE-APODIZED-DIFFRACTIVE PERFORMANT INTERMEDIATE VISION OUTSTANDING FAR AND NEAR VISION

STANDARD BIFOCAL LENS

STANDARD TRIFOCAL LENS

BI-FLEX M WITH PAD TECHNOLOGY

1.2

1.2

1.0

1.0

0.8

0.8

0.6

0.6 Functional vision

0 Distance Intermediate

Near

0 Distance

Intermediate

Near

Distance

Intermediate

Near

4

COVER STORY: CATARACT & REFRACTIVE LENS

MULTIFOCAL IOLS AND BEYOND

Static-optic presbyopia IOLs make optical trade-offs to meet patient needs. Howard Larkin reports

A

functional accommodative intraocular lens (IOL) may exist somewhere in the future, but meanwhile presbyopic patients in the present would like to have functional vision at more than one distance. The new wave of multifocal and extended depth of focus (EDOF) IOLs are helping overcome some of the existing limitations to current presbyobic IOL solutions.

A wide variety of lenses that leverage static optical principles to address presbyopia are now available or close to market. These include multifocal lenses that provide two or three focal depths, as well as lenses that employ diffraction, a small aperture, spherical aberration or polyfocality to smoothly extend depth of focus. Monovision, using monofocal lenses of differing powers or to enhance the effect of newer EDOF lenses, also remains a viable solution.

But physics is a harsh taskmaster.

Dividing or stretching the focal point of light entering the eye inevitably involves EUROTIMES | FEBRUARY 2016

trade-offs. Generally speaking, seeing clearly at more than one distance comes at the cost of reduced contrast sensitivity, low-light vision and uncorrected visual acuity at all distances – as well as glare, halos, starbursts and sundry dysphotopsia.

Some of these trade-offs are evident in objective tests of presbyopia correcting IOL optics, such as wavefront and point spread analyses. Some also appear in subjective defocus curves and contrast sensitivity tests, and functional tests such as reading speed.

How they will play out in a given patient is another matter. The anatomy and neurophysiology of human vision makes some aberrations easier to cope with than others – and this capacity varies by individual. Also variable is patients’ willingness to put up with a given trade-off, such as better reading vision for limited night driving. And some effects that are vital to everyday function, such as speed of shifting focus and depth perception, are difficult to test, said Ioannis G Pallikaris MD, PhD, of the University of Crete, Greece. He suggests that standardised tests be developed for lens performance to enable comparisons.

For best results, the trade-offs of various static presbyopic IOLs, gleaned from both specifications and clinical experience, must be matched to individual patient needs, according to surgeons experienced with a range of options.

Below are some of the major static optic types and how they perform.

MULTIFOCALS MADE MANAGEABLE Multifocal IOLs address presbyopia by splitting incoming light into two or three distinct focal points, typically with a near add of 2.5D to 4.0D, with a third intermediate step for trifocals. With their high near add, multifocals generally provide good reading vision, leading to more patients reporting complete spectacle independence than with monofocal or even newer EDOF lenses.

The trade-off is image quality. Splitting light means that less light is available to produce an image at any given distance.

This translates to reduced contrast sensitivity. That an out-of-focus image is also superimposed further increases blur, while the complex diffractive or refractive

COVER STORY: CATARACT & REFRACTIVE LENS

Courtesy of Ioannis G Pallikaris MD, PhD A typical iTtrace analysis of a WIOL, far and near performance. The range of the refraction for near is within 6.55 dioptres with the maximal effect on -4.84 and the mean refractive difference between far and near -1.00 dioptres, but because of extended depth of focus the maximum is up to -3.66 dioptres

lens is the Tecnis Symfony (Abbott Medical Optics). Compared with a similar aspheric monofocal lens, the Symfony lens’ diffractive echelette optic elongates its focal point by approximately 1.75 dioptres, according to a recent clinical study by Joseph JK Ma MD, FRCSC, of the University of Toronto, Canada. This improves visual acuity continuously across the defocus curve, yielding binocular vision of 20/25 or better over approximately -2.5D of defocus when extended with micromonovision targeting -0.75D in the non-dominant eye. This also results in excellent binocular intermediate stereo vision from the bilateral overlapping defocus curves.

The Symfony also corrects for chromatic aberration, improving contrast sensitivity, which is comparable to a monofocal lens.

However, the most significant trade-off is less near vision when compared with multifocals IOLs. It’s a trade-off many patients are more willing to make in order to minimise the compromise in the quality of their distance vision, said Dr Ma. In his first 85 Symfony patients, contrast sensitivity, glare and halos were similar to those seen with monofocal lenses, while providing intermediate and even reading vision when combined with mini-monovision.

However, the lens is not entirely without symptoms, and there can still be unique night-time symptoms associated with the lens, such as a web-like effect associated with red lights, that appears in some patients, does not appear to be debilitating, and improves dramatically with time.

Courtesy of Joseph JK Ma MD, FRCSC

optics needed to produce multifocality also tend to scatter light, producing dysphotopsia.

This trade-off is well documented, noted Oliver Findl MD, of Hanusch Hospital, Vienna, Austria. He cited a meta-analysis of 16 masked randomised controlled trials involving more than 1,600 patients that found multifocal lenses improved near vision and spectacle independence compared with monofocals, but multifocals also reduced contrast sensitivity, and were twice as likely to produce annoying or disabling glare and dazzle (Calladine D et al. Cochrane 2012).

Dr Findl has seen similar results in his own research, along with higher rates of explants for multifocal lenses (Wilkins MR et al. Ophthalmology. 2013;120(12): 2449– 2455). Indeed, the number of explanted multifocal lenses reported through the ESCRS/ASCRS online survey has grown for the last several years, with the vast majority removed because of glare and other dysphotopsia.

However, some newer multifocal IOL designs address these issues, said Jorge L Alió MD, PhD, of Vissum Ophthalmologic Institute, Alicante, Spain. His tests show that the Zeiss AT LISA trifocal and trifocal toric lenses provide better contrast sensitivity at all spatial frequencies than several other multifocals he implants, with values close to a monofocal (Mojzis P, Alio JL et al. JCRS 2014;40:60-69. JCRS in press).

Glare is also less than earlier lenses, which he attributes to advanced optic design, which Zeiss says reduces light scatter and photic effects by smoothing transitions between optic zones on the lens.

AT LISA tri is an 11.0mm singlepiece plate haptic design with a 6.0mm diffractive optic with adds of +3.33D for near and +1.66D for intermediate composed of a hydrophilic acrylic with hydrophobic surface. Dr Alió pointed out the its defocus curve lacks the pronounced dip at intermediate distances of bifocal IOLs, mimicking the defocus performance of a functional human eye. He considers this an important indicator of real-world lens performance as defocus is a function of neuroprocessing as well as lens optics.

“It correlates well with the quality of vision as perceived by the patient in terms of multifocality,” he said.

Dr Findl also finds the AT LISA trifocal, along with the FineVision trifocal, to be tolerated better than bifocal IOLs. He will implant them in a hyperopic patient but is reluctant to do so in emmetropic or myopic patients. “They are used to good quality near vision and often don’t do well with a multifocal,” he said. He also cautions that reduced contrast sensitivity can be a problem for patients who later develop retinal issues.

DIFFRACTIVE EDOF Extended depth of field IOLs offer another presbyopic solution. One such

5

Clinical spherical equivalent refractive tolerance in the Symfony lens

EUROTIMES | FEBRUARY 2016

COVER STORY: CATARACT & REFRACTIVE LENS

Courtesy of Robert Edward Ang MD

6

AcuFocus IC-8 small-aperture IOL

Although the effect can be different between patients, in addition to providing 20/20 vision up to -2.0D defocus in some patients, the lens is very forgiving of astigmatism, Dr Ma said. He implanted one in a lens exchange in a pseudophakic patient with forme fruste keratoconus.

Despite some asymmetric astigmatism, the eye had 20/25 uncorrected distance vision with spherical equivalent tolerance up to -1.75D, allowing her to both drive and read a computer monitor easily without glasses.

Even more importantly, the patient was as satisfied with the quality of vision in the EDOF lens as with the previous monofocal in that eye as well as the monofocal in the fellow eye, Dr Ma said. “As beautiful as the defocus curve looks, we want to see how it performs in the real world.” In this case, well enough that the patient subsequently referred her mother.

SMALL APERTURE EDOF The IC-8 IOL (AcuFocus) extends depth of focus using the pinhole effect, incorporating a 3.2mm diameter mask with a 1.36mm central aperture on a 6.0mm one-piece hydrophobic acrylic lens. This broadens the defocus curve on both sides of the focal point, resulting in vision of 20/32 or better over about -2.0D defocus when targeted for plano distance vision, said Robert Edward Ang MD, Manila, The Philippines.

Minimonovision broadens that to about -3.0D, Dr Ang said. Stereopsis is also achieved over a range of distance.

In a study of 16 patients implanted in the non-dominant eye targeting plano distance, mean uncorrected binocular distance vision was 20/20, intermediate

20/25, and near J2 or about 20/25 12 months post-op, Dr Ang said. The tradeoff is a slight reduction in distance visual acuity (no more than one line) and a small loss of contrast sensitivity in the IC-8 implanted eye, about 0.1 to 0.2 log units compared with the monofocal fellow eye.

However, the loss of night contrast sensitivity is not enough to affect patients’ function, Dr Ang said. Due to less glare and halos, night vision is better than with trifocal IOLs he also implants, and is good even in 10 patients implanted bilaterally with the IC-8. “One of them rides a motorcycle at night,” Dr Ang said.

However, the IC-8 does not provide as much near add as the trifocals.

The current lens design requires an incision of about 3.0mm, said Dr Ang. However, the pinhole optic is more forgiving of refractive error due to the uninterrupted depth of focus and even tolerates up to 1.50D of astigmatism.

The mask raises questions about viewing the retina, but it is possible to see around it to do any kind of retinal exam and to perform surgical procedures, Dr Ang said. Likewise, he has performed posterior capsulotomies on patients with no issues.

ADJUSTABLE SPHERICAL ABERRATION EDOF Inducing spherical aberration in the lens is yet another way of extending depth of focus.

This can be done with the Light Adjustable Lens (LAL, Calhoun Vision). This threepiece IOL with 6.0mm optic is constructed of ultraviolet-sensitive silicone polymers that allow spherical and toric adjustment of about 2.0D as well as correction of

Using adaptive optics to determine the best combination... the LAL allows for a truly customised solution Pablo Artal PhD EUROTIMES | FEBRUARY 2016

aberrations using a special lamp. With the dominant eye at emmetropia, inducing -0.23 microns of spherical aberration in the non-dominant eye improved intermediate range vision to 0.94 or nearly 20/20 at 40cm, and 0.73 or about 20/30 at 30cm.

The combination also delivered binocular uncorrected distance visual acuity of 1.1 or a little better than 20/20 (Villegas EA et al. AJO 2014;157(1):142-149).

The trade-off is slightly worse distance vision in the non-dominant eye, and less near vison than a multifocal. Also, patients vary in their tolerance of spherical aberration, said Pablo Artal PhD, of the University of Murcia, Spain. However, using adaptive optics to determine the best combination of spherical aberration and defocus (sphere) correction for a given patient, the LAL allows for a truly customised solution, he added.

POLYFOCALITY The WIOL-CF (Medicem) is a hydrogel lens 9.0mm in diameter with no haptics designed to fill the capsular bag and mimic the shape and function of the natural crystalline lens. It incorporates continuous aspheric hyperboloid polyfocal optic with higher power at the centre designed to provide up to 2.0D of continuous pseudoaccommodation, and may deform under accommodative effort to provide additional add power.

The trade-off is less near vision than a multifocal. In a study conducted by Dr Pallikaris, 72 per cent of patients achieved J2 or better near vision with 20/20 distance.

Other studies have found uncorrected near vision of J3. Photopic and mesopic contrast sensitivity is within normal range.

The lens also provides good stereopsis. Ray tracing shows a depth of focus of five to six dioptres at the lens centre, though in a very narrow zone. Dr Pallikaris expected a high myopic shift in the bright Greek sun, but patients notice it much less than he suspected. “It mimics somehow natural pseudo-accommodation that is quite acceptable to the patient,” he said.

Dr Pallikaris inserts the lens through a 2.8mm incision in a dehydrated state. The lens hydrates to fill the capsular bag in the first 48 hours.

While the various EDOF lenses are less prone to photic phenomena and provide continuous defocus, multifocals still provide better near vision, Dr Ang noted.

“The EDOF lenses are here to stay but you cannot do away with the multifocal.”

In the end, patient needs drive the decision.

Ioannis G Pallikaris: pallikaris@dunyagoz.com Oliver Findl: oliver@findl.at Jorge L Alió: jlalio@vissum.com Joseph JK Ma: joseph.ma@utoronto.ca Robert Edward Ang: rtang@asianeyeinstitute.com Pablo Artal: Pablo@um.es

10–14 September

2016

XXXIV Congress of the ESCRS Bella Center, Denmark

Abstract Submission Deadline 15 March 2016

www.escrs.org /ESCRS

@ESCRSOfficial

ESCRS

8

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

NEW LENSES Accommodative IOLs likely to edge out multifocals as presbyopia solution.

Dermot McGrath reports

D

espite improvements in recent years, multifocal intraocular lenses (IOLs) will never provide a silver bullet solution to presbyopia, Jorge L Alió MD, PhD told delegates attending the 2015 Congress of the European Society of Ophthalmology (SOE) in Vienna, Austria.

“The latest generation of multifocal IOLs offers a real improvement on earlier iterations of the technology with better range of foci, less loss of contrast sensitivity function, fewer issues with halos and glare and better patient satisfaction,” he said.

Nevertheless, despite these advances Dr Alió believes that multifocal lenses will ultimately come to be supplanted by accommodative IOLs. “We need to bear in mind that multifocal IOLs are not physiological and they will always require some degree of neuroadaptation. Once accommodative IOLs are developed adequately, multifocal IOLs will be unable to compete as happened in the past with pseudophakic glasses and IOLs,” said Dr Alió, of Vissum Ophthalmologic Institute, Alicante, Spain.

LIMITED ENERGY By definition, multifocal IOLs divide light into different foci, with limited energy available for each focal point, said Dr Alió. The overlapping of different foci is neither physiological nor normal in the evolution of humans or animals, he noted, and therefore the brain is required to adapt to the changes induced in the quality of the retinal image caused by the dispersion of light. Another challenge

Glaucoma Day 2016 ESCRS

Friday 9 September

Immediately preceding the XXXIV Congress of the ESCRS 10–14 September

facing multifocal IOLs is the superposition of images causing glare and halos, although modifications in lens design have gone some way towards addressing these concerns, said Dr Alió.

Dr Alió said that the latest generation of extended depth-of-focus IOLs were a clear improvement on earlier multifocal designs.

The Tecnis Symfony extended depth of vision IOL (Abbott Medical Optics), for instance, uses three principal optical strategies to achieve optimal visual quality for the patient: a proprietary diffractive echelette design to elongate the focus of the eye and deliver an extended range of vision; achromatic technology to reduce chromatic aberration and enhance contrast sensitivity; and, finally, spherical aberration control.

Such improvements, however, will not be sufficient to enable multifocal IOLs to compete with the next generation of accommodative IOLs, said Dr Alió.

Accommodative IOLs seek to induce a progressive change in the power of the lens related to active ciliary body action, thereby mimicking the natural physiological process of accommodation that is lost as we get older, said Dr Alió.

IOL manufacturers have adopted three basic approaches to try to replicate the process of accommodation, he explained: inducing a change in axial position with a single or dual optic, a change in shape or curvature drawing on capsular bag elasticity, the zonularcapsular diaphragm and changes in vitreous-capsular pressure, or a change in refractive index or power.

Of the newer accommodating IOLs, Dr Alió said that two of them – FluidVision (PowerVision) and Sapphire (Elenza) – are designed for capsular bag placement and two – DynaCurve (NuLens) and Lumina (Akkolens/Oculentis) – are meant for sulcus placement.

CAPSULAR BAG Dr Alió said that the capsular bag seems to be an inadequate location for accommodating IOLs, mainly due to the fibrosis and atrophy that occur after crystalline lens removal.

“The capsular bag is the basal membrane of the lens epithelium.

Once the crystalline lens has been removed, it no longer has any reason to exist. With no function and no anatomy to support, fibrosis and atrophy are unavoidable and the capsular bag cannot function in the long term when it has been emptied,” he said.

By contrast, the forces that continue to be generated by the zonular-capsular system suggest that this might be a more viable location for accommodating IOL designs, he said.

A pilot study of the Lumina varifocal lens seems to confirm the accommodative potential of this sulcus-implanted IOL, said Dr Alió.

The lens was implanted in 51 eyes and compared to a monofocal control lens in 22 eyes (AcrySof ResTor, Alcon). Objective measurements with the WAM-5500 (Grand Seiko) and defocus curves showed that the Lumina successfully restored variable amounts of astigmatism and provides accommodative performance in the range of 1.50D to 6.00D. Jorge L Alió: jlalio@vissum.com

Scientific Programme organised by

www.escrs.org

The capsular bag is the basal membrane of the lens epithelium Jorge L Alió MD, PhD EUROTIMES | FEBRUARY 2016

SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

9

ENHANCED IOL DEPTH New pretender to the presbyopia throne. Dermot McGrath reports

A

Worldwide fastest

new generation of extended depth of focus intraocular lenses (IOLs) may change the way surgeons approach presbyopia treatments, according to a presentation at the 2015 Congress of the European Society of Ophthalmology (SOE) in Vienna, Austria.

“The latest generation IOLs provide excellent quantity and quality of vision at all distances with a greatly reduced incidence of the adverse optical symptoms that have historically been associated with multifocal IOLs,” said Aylin Kılıç MD, adding that patients have been demanding such a solution for years.

Dr Kılıç, Dunya Eye Hospital, Istanbul, Turkey, said that today’s patients are more demanding about their visual requirements after cataract surgery.

“Most patients now expect to maintain functional near vision in low light conditions, to have perfect distance vision and high contrast sensitivity, and to be independent from glasses for most if not all of their daily activities,” she said.

Dr Kılıç noted that the Symfony extended depth-of-vision IOL (Abbott Medical Optics) uses three principal optical strategies to achieve optimal visual quality for the patient: a proprietary diffractive echelette design to elongate the focus of the eye and deliver an extended range of vision; achromatic technology to reduce chromatic aberration and enhance contrast sensitivity; and, finally, spherical aberration control.

Explaining the echelette design concept, Dr Kılıç said that it is essentially an optical component with a periodic structure that splits and diffracts lights into several beams travelling in different directions. “With this approach the split of light is incomplete, and therefore the same is true for the separation of foci. This incomplete separation of foci contributes to an extended depth-of-focus and the attenuation of dysphotopsia phenomena such as halos and glare,” she added.

Dr Kılıç said that early clinical trials of the lens showed that the binocular defocus curve of the Symfony was associated with a clinically significant increase in depth-of-focus compared to a monofocal IOL. Patients implanted with the extended range-ofvision IOL had a sustained mean visual acuity of 20/20 or better through 1.5D of defocus and a full range of functional vision of 20/40 or better through 2.5 of defocus.

While her own clinical experience with the lens was limited to 18 eyes of nine patients, Dr Kılıç said that the results thus far have been positive overall, with all eyes achieving uncorrected binocular distance vision of 20/20 or better and no problems of halos or glare. Binocular near vision outcomes were also very good, with only one patient requiring reading glasses for some tasks, and that particular case was due to an error in preoperative biometry, explained Dr Kılıç.

Aylin Kılıç: aylinkilicdr@gmail.com

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SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

A three-piece silicone lens explanted within the capsular bag because of late postoperative subluxation/dislocation

LOOMING EPIDEMIC

Sharp increase in incidence of late IOL dislocations likely to impose increasing burden on surgeons and patients. Roibeard O’hEineachain reports

T

here has been a sharp increase in the rate of late intraocular lens (IOL) dislocations in Sweden and other countries over the last decade, and the number of patients with the complication is likely to increase in coming years, said Ulf Stenevi MD, Sahlgrenska University Hospital, Mölndal, Sweden, at the XXXIII Congress of the ESCRS in Barcelona.

He noted that studies carried out in Sweden show that the rate of late IOL dislocation in that country – usually occurring several years after IOL implantation – began to increase markedly starting around 2004 and that the complication occurs in around a half a per cent to one per cent of patients. Research also suggests that other countries may be experiencing a similar trend.

The increase in late IOL and capsule subluxation appeared to follow, in a delayed fashion, the widespread introduction of phacoemulsification in the 1990s. If current trends continue, the incidence of IOL dislocations is likely to double in the next seven to eight years, given the increasing numbers of cataract procedures performed annually.

He noted that all authors agree that pseudoexfoliation is the most important risk factor for IOL dislocation. That is probably due to the weaker zonules and EUROTIMES | FEBRUARY 2016

thinner, more brittle capsules in eyes with the condition. Other risk factors include concomitant eye disease, previous eye surgery, long axial length, and long phacoemulsification time.

He recommended referring patients at high risk for IOL dislocation to the most experienced surgeons available, and he suggested that extracapsular cataract surgery might be the best option in some cases.

CAPSULAR CONTRACTION In a related presentation, Liliana Werner MD, PhD, John A Moran Eye Center, University of Utah, Salt Lake City, USA, noted that histopathological studies indicate that dislocation and subluxation occurs with a broad range of IOL designs and that capsular tension rings do not prevent the complication or the capsular contraction that can precipitate it.

In addition, a recent study conducted at the Moran Eye Center

showed that histopathology detected pseudoexfoliation in 26 (65 per cent) of 40 consecutive explanted specimens, although the condition was noted in only 13 of the eyes involved at the time of cataract surgery, a mean of 8.5 years earlier.

Miad Pour Sadeghian MD, Goethe University Frankfurt, Germany, where the explantations were mainly performed

by Prof Thomas Kohnen, noted that following the explantations most eyes received retropupillary Artisan® IOLs. The mean postoperative uncorrected visual acuity was 1.250 logMAR, compared to 1.476 logMAR upon admission, and their mean postoperative best corrected visual acuity was 0.733 logMAR. Ulf Stenevi: ulf.stenevi@oft.gu.se Liliana Werner: werner.liliana@gmail.com Miad Pour Sadeghian, C/O Thomas Kohnen: kohnen@em.uni-frankfurt.de

There has been a sharp increase in the rate of late intraocular lens (IOL) dislocations in Sweden and other countries over the last decade...

Ulf Stenevi MD

Courtesy of Liliana Werner MD, PhD

10

FOUR EVENTS ONE VENUE Bella Center, Denmark

XXXIV Congress of the ESCRS

16th EURETINA Congress

7th EuCornea Congress

WSPOS Paediatric Subspecialty Day

10–14 September www.escrs.org

8–11 September www.euretina.org

9–10 September www.eucornea.org

9 September www.wspos.org

12

CATARACT & REFRACTIVE

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ADVANTAGES OF ISBCS Negligible risk of endophthalmitis in simultaneous bilateral cataract surgery. Dermot McGrath reports

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he advantages of immediately sequential bilateral cataract surgery (ISBCS) so outweigh the risks that consideration should be given to widespread adoption of the practice, Charles Claoué MD told delegates attending the 2015 Congress of the European Society of Ophthalmology (SOE) in Vienna, Austria.

Discussing the current risk of functional or bilateral blindness from endophthalmitis stemming from ISBCS, Prof Claoué, of Queen’s Hospital, London, UK, said that it was important to base one’s judgment on statistical evidence rather than gut feeling or a vague sense that ISBCS might be riskier to the patient.

“The reality is that when we examine the risk of being functionally blind from simultaneous bilateral endophthalmitis after ISBCS, it is lower by more than a factor of 10 than the risk of being struck by lightning and much lower than the risk from death from a general anaesthetic,” he said.

Prof Claoué said that it was important to define risk and the role it plays in our lives. “Often we want to stick our head in the sand and pretend that risk is not there. Or at the other end of the scale we can think we are somehow immune to risk and will always emerge unscathed. But there is an unpredictability to risk that we often choose to ignore,” he said.

Risk is defined as the probability of an adverse effect from a defined activity, or the probability of losing something of value, said Prof Claoué. “Throughout life, we choose or avoid risk. Some of us choose to smoke, to drive fast cars, to practise unsafe sex, to travel by plane, car or motorbike, to undergo surgery, and so on,” he said.

The risk of endophthalmitis in routine unilateral cataract surgery is about 0.029 per cent, based on data from the Swedish cataract registry, said Prof Claoué.

“If you take this figure and calculate the risk Charles Claoué of bilateral simultaneous endophthalmitis after ISBCS, the figure is 0.00000841 per cent, which is about one case in 11.9 million, assuming it is a random event,” he added.

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A common objection to this statistic is the so-called “linkage factor” which claims that these are not independent events, said Prof. Claoué. “While second eye endophthalmitis after delayed surgery is well described, there is no data to suggest that endophthalmitis in one eye is a risk factor for an increased risk in the second eye. So when people talk about linkage factors and saying that they are not random events, ask them for their data because at present I do not see it,” he said.

To put the statistics in context, Prof. Claoué said that a surgeon would need to operate on every single person in a country with a population the size of Belgium (11 million) in order to stand a reasonable chance of seeing one patient with bilateral simultaneous endophthalmitis.

Charles Claoué: charles@dbcg.co.uk

EUROTIMES | FEBRUARY 2016

CATARACT & REFRACTIVE

ANTISEPSIS PROTOCOL

Henderson Instruments for toric IOLs

Chlorhexidine effective for preoperative prophylaxis.

Dermot McGrath reports

C

hlorhexidine appears to be as effective as the more widely used povidone-iodine for preoperative antisepsis protocol in cataract surgery, according to a presentation at the 2015 Congress of the European Society of Ophthalmology (SOE) in Vienna, Austria.

“While the most widespread preoperative antisepsis protocol in use today includes povidone-iodine, the evidence suggests that chlorhexidine is equally effective. In case of hypersensitivity to or unavailability of one of the substances, the other formulation may be used. Most important of all, however, is to use a conjunctival antiseptic solution together with intracameral antibiotics,” said Bjorn Johansson MD, PhD, FEBO, Linkoping University, Sweden.

Quoting from the ESCRS Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery, Dr Johansson said that “more than any other form of preoperative antisepsis, the literature supports the essential role of povidoneiodine for ocular surface preparation prior to cataract surgery”.

However, he noted that the guidelines also state that “where povidone-iodine is contraindicated aqueous chlorhexidine 0.05 per cent may be used”.

Discussing the properties of the two compounds, Dr Johansson said that povidone-iodine reacts in electrophilic reactions with enzymes of the respiratory chain of the aerobic microorganisms, as well as with amino acids from the cell membrane proteins with less toxicity than other iodine formulations. Chlorhexidine, which was discovered in 1946 and first used in clinical practice in the 1950s, derives its effect by damaging outer cell layers and disrupting the cell membrane.

Known adverse effects of povidone-iodine include corneal injury, toxic anterior segment syndrome (TASS), rash, and anaphylactic shock. Its use is contraindicated in hyperthyreosis and iodine allergy. Side effects of chlorhexidine use include damage to the corneal endothelium, epithelial haze, urticaria, dyspnoea and anaphylactic shock, he said.

Looking at the evidence in the scientific literature, Dr Johansson cited a Cochrane report Bjorn Johansson appraising the outcomes of nine randomised controlled trials which found moderate quality evidence supporting chlorhexidine over povidone-iodine for preoperative skin antisepsis to prevent surgical site infection, and that its use is associated with fewer positive skin culture results after application. Another study by Barkana et al concluded that povidone-iodine four per cent, ofloxacin 0.3 per cent or chlorhexidine 0.05 per cent may all be considered as viable options for a quick prophylaxis against infection.

After Dr Johansson’s own clinic changed its infection prophylaxis routines by first introducing intracameral cefuroxime injection, and soon thereafter changing the preoperative rinsing solution from physiological saline to chlorhexidine in 2002, there followed over 4,600 cataract surgeries without postoperative infection, he said.

marking pattern

Mark the patient

Using this marker the surgeon impresses three dot-shaped landmarks at the 3, 6, & 9 o’clock positions. The tips of the prongs are flattened to prevent damage to the epithelium even if the patient inadvertently moves.

K3-7908 Henderson Alignment Marker

Orient the gauge to the marks

To correctly position the gauge, the surgeon simply aligns the notches on the inside edge of this instrument with the dots produced by the Henderson Alignment Marker. Also available with teeth for better fixation.

K3-7904 Henderson Degree Gauge K3-7905 Henderson Degree Gauge, with teeth

Mark the axis of astigmatism

Once the gauge is oriented, the surgeon simply aligns the marks of this instrument with the desired degree lines on the gauge.

This produces two thin lines along the axis of astigmatism which can be used to correctly align the toric IOL. K3-7912 Henderson Toric IOL Marker

Instruments designed by Bonnie Henderson, MD of Boston, Massachusetts

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Bjorn Johansson: bjorn.johansson@regionostergotland.se EUROTIMES | FEBRUARY 2016

13

14

CATARACT & REFRACTIVE

ALBERT GALAND An appreciation of one of the great pioneers of ophthalmology.

I

By Prof Marie-José Tassignon

t is with immense sadness that we announce the passing of Albert Galand MD, PhD, honorary member of the Belgian Society of Cataract and Refractive Surgeons (BSCRS) and former board member of the ESCRS. Prof Galand, who passed away on 22 December 2015, was also a member of the ESCRS Video Competition judging panel.

He was born in Brussels in 1938, and graduated from the University of Liège in 1964. Prof Galand later became Chairman of the Department of Ophthalmology of the University of Liège (1992–2004). During his tenure, he trained many ophthalmology fellows who now serve as professors.

PIONEERING WORK Prof Galand was also a prolific researcher in the field of intraocular lens (IOL) design. With his pioneering work in primary posterior circular continuous capsulorhexis, Prof Galand was one of the key leaders in the field of posterior capsule opacification and IOL design.

He organised international symposia on a regular basis called “Intercapsula”, to which very well known colleagues were invited, including Michael Blumenthal, Charles Kelman and Jan Worst. He developed the technique called the “capsular envelope technique”, which was used for many years before the invention of the anterior capsulorhexis by Thomas Neuhann.

He was a member of the International Intra-Ocular Implant Club (IIIC) from 1984 and presented the IIIC medal lecture on the topic of “In the bag, back to the source” in 2010.

Prof Galand was an active player in the international ophthalmic community. He participated in international scientific organisations, including the American Society of Cataract and Refractive Surgeons (ASCRS) and the Association for Research in Vision and Ophthalmology (ARVO).

EXEMPLARY LEADERSHIP At the start of my career as chairperson of the Department of Ophthalmology of the Antwerp University Hospital in 1991, I had a lot of contact with Prof Galand. We were both founding members of the BSCRS. Prof Galand proposed my name to the ESCRS, which resulted in my election as a member of the board in 1997. I have always been very thankful to Prof Galand for having been instrumental in initiating my international career.

Prof Galand was invited to speak at the meetings of many international societies, in recognition of his exemplary leadership in the field of ophthalmology. With his dedication, he made substantial improvements in ophthalmic teaching and training in Belgium and beyond.

The ESCRS extends its sympathy to his wife Hafida Sennouni and his children Vincent, Catherine, Samira, Arnaud and Jérôme.

Prof Dr Marie-José Tassignon was President of the ESCRS from 2004-2005

The 2005 Alcon Video Award judges at the ESCRS Congress in Lisbon, Portugal. Standing (left-right): San Ong, Camille Budo, Richard Packard, Okihiro Nishi, Ekkehard Fabian, Elie Dahan, Vittorio Picardo. Seated (left to right): Albert Galand, Michael Blumenthal, Chandrappa Reshmi

EUROTIMES | FEBRUARY 2016

CORNEA

CROSSLINKING: NEW APPROACH Topography-guided crosslinking shows promise.

Tired of seeing those unhappy patients?

Dermot McGrath reports

T

opography-guided individualised crosslinking may offer significant refractive advantages over conventional corneal crosslinking (CXL) in keratoconus, according to Anders Behndig MD, PhD. “Initial results with this new treatment approach are encouraging, but obviously need to be confirmed in larger studies with longer follow-up. In this first attempt to control and improve the refractive outcomes after CXL, the effects are promising. With further fine-tuning, the method has the potential to become a valuable addition to the therapeutic arsenal in keratoconus,” Dr Behndig told delegates at the XXXIII Congress of the ESCRS in Barcelona, Spain.

Discussing the rationale for the KXL II device (Avedro, Inc.), Dr Behndig, of Umeå University Hospital, Umeå, Sweden, said there was clearly a need for more accurate and targeted CXL treatments which take account of the patient’s refractive outcome, as well as the primary need to halt the progression of the disease.

“The clinical manifestations of keratoconus can range from slight corneal asymmetry to pronounced thinning, cone formation and scarring at the more advanced stages of the disease. Despite this range, we still have only one standard CXL treatment protocol,” he said.

He explained that KXL II uses an asymmetrical treatment zone, the size and location of which is determined by the “centre of mass” of the cone as measured by Pentacam® HR (Oculus GmbH). This approach spares a 2.0mm optical zone, with energy distribution determined by the maximum keratometry reading (Kmax) ranging from 7.2 to 15J/cm2.

The system uses programmable and customisable illumination patterns with real-time eye tracking designed to enhance the refractive improvement after CXL. In Dr Behndig’s ongoing study, which started in March 2014, 50 eyes were randomised between KXL II individualised treatment and conventional CXL, with all 25 eyes treated in both groups.

The spherical refraction showed improvement at six months after KXL II. Cylinder was also reduced in the KXL II treated Anders Behndig patients but the difference was not statistically significant. Uncorrected visual acuity (UCVA) was worse at one month in CXL treated eyes, noted Dr Behndig.

“This is not uncommon in conventional crosslinking, but we did not see the same reduction in the KXL II treated eyes.

This likely owes to the fact that the treatment spares the 2.0mm optical zone,” he said.

A statistically significant improvement in UCVA was also attained in the KXL II group compared to CXL treated patients at three and six months.

Corneal asymmetry as measured by saggital curvature maps showed enhanced inferior corneal flattening and reduction in Kmax in KXL II patients compared to those treated with conventional CXL. No differences in endothelial cell count were seen between the two treatments.

Anders Behndig: anders.behndig@umu.se EUROTIMES | FEBRUARY 2016

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16

CORNEA

EPI-ON CXL EFFICACY Stronger evidence needed to determine epi-on CXL efficacy.

Dermot McGrath reports

M

ore clinical studies with longer follow-up and especially randomised, controlled trials are required to ascertain the efficacy of “epithelium-on” corneal crosslinking (CXL) compared to the current gold standard of “epithelium-off” CXL, David O’Brart MD told delegates attending the 6th EuCornea Congress in Barcelona, Spain.

“The evidence to date shows that epi-on CXL has limited efficacy compared to epi-off CXL. Its efficacy is limited by stromal riboflavin absorption and masking of the ultraviolet absorption by the epithelium,” he said.

By contrast, there exists a large body of clinical evidence showing that traditional epithelium-off CXL is safe and effective for routine use treating keratoconus and post-LASIK ectasia, said Dr O’Brart, UK. “Since the introduction of CXL over a decade ago there have been multiple published case series with several years follow-up, including advanced and paediatric keratoconus and other forms of ectasia which have shown stabilisation in the vast majority of cases, few complications and significant improvements in vision, topographic parameters and higher order aberrations,” he said.

These results have been confirmed by other long-term studies, some of which were randomised controlled trials, showing improvements in visual and topographic parameters up to seven and 10 years after surgery, said Dr O’Brart.

DISCOMFORT TO PATIENTS Nevertheless, while the efficacy of CXL with the epithelium removed is not in doubt, the major downsides of the procedure are the discomfort to patients and risk of complications.

“These young patients are miserable for the immediate postoperative period, with severe postoperative pain for 24 to 48 hours, blurred vision for two to four weeks and they can’t wear their contact lenses for three to four weeks. We also see sightthreatening complications which are thankfully rare such as haze, scarring, infectious or non-infectious keratitis, persistent corneal oedema and excessive flattening,” he said.

Hence the appeal of epi-on CXL, said Dr O’Brart, with the promise of less pain, faster visual recovery, and less risk of infection as the epithelial barrier is still in place. Leaving the epithelium intact should also result in a reduced risk of stromal scarring, haze and corneal melt, with less stromal oedema and endothelial damage as well as peri-operative dehydration, he added.

Current epi-on methods that have been tried, with mixed results, include mechanical (partial epithelial disruption), chemical enhancers (benzalkonium chloride, BAC), edetate sodium (EDTA) and channel forming peptides), and iontophoresis. Investigators have also tried modifying the riboflavin solution, application time and/or the ultraviolet dosage to increase absorption of the riboflavin in the stroma, he said.

The 18 month outcomes of CXL using grid-pattern epithelial scratches and riboflavin 0.1 per cent and trometamol (Ricrolin TE) showed good improvement in visual acuity and reduction in apex power in 28 eyes, but three patients progressed after two years, said Dr O’Brart.

Another study by Filippello et al (JCRS 2012;38:283-91) found that chemical enhancement with Ricrolin was safe and well tolerated with rapid visual recovery and little postoperative pain.

While the results were comparable to epi-off CXL, randomised controlled trials were needed to confirm this, said Dr O’Brart.

While studies by Buzonetti (JRS 2012; 28: 763) and Caporossi (JCRS;39:1157) showed improvement in visual acuity, keratoconus progression in paediatric cases was a concern in both studies.

A literature review by Shalchi et al (Eye. 2015 Jan;29(1):15-29) concluded that while epi-on and epi-off CXL studies both showed improvement in visual acuity and refractive cylinder, Kmax worsened in most epi-off studies. However, adverse events were reported more with epithelium-off studies.

Iontophoresis, which uses electrical currents for transdermal delivery, is another promising approach to epi-on CXL, said Dr O’ Brart, but more studies are needed to determine the optimal protocol. A randomised controlled trial currently under way at St Thomas’ Hospital in London, UK, of epi-off CXL versus iontophoresis CXL (iCXL), using a modified protocol, should help to advance research in this area, he said.

“What we really need is some way of accurately assessing the cross-linking effect to be able to optimise our protocols in terms not only for epi-on and epi-off but also for accelerated CXL before we can really move ahead,” he concluded.

David O’Brart: DavidOBrart@aol.com

EUROTIMES | FEBRUARY 2016

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CORNEA

SURGICAL INNOVATIONS Latest iterations of endothelial keratoplasty showing potential.

Sean Henahan reports

T

wo of the latest iterations of endothelial keratoplasty have the potential to simplify surgery and to make more efficient use of donor tissue, Gerrit Melles MD, PhD, Director, Netherlands Institute for Innovative Ocular Surgery (NIIOS), told a session of the World Cornea Congress VII in San Diego, USA. Dr Melles, who played a key role in the development of Descemet’s membrane endothelial keratoplasty (DMEK), discussed hemi-DMEK and Descemet’s membrane mediated endothelial transfer (DMET).

“The first problem facing our field is that we have a tendency to produce more acronyms than Apple can produce apps,” he said.

“With all these new innovations you have to evaluate from a starting point, probably DMEK, which produces very good results for us. If you want to come up with something new it really has to be much better, otherwise why do it?”

DMET involves injecting free-floating donor Descemet graft in the recipient anterior chamber following Descemetorhexis on the host. The cornea clears over a period of weeks, with endothelial tissue covering the exposed posterior stroma. Patients undergoing DMET experience visual results similar to those seen with DMEK. Results seen in the treatment of Fuchs' dystrophy have caused Dr Melles to question the nature of that disorder.

“We’ve seen a lot of evidence that host cells in Fuchs’ are still potent, and capable of migrating. If you remove the Descemet’s membrane, the cells in Fuchs’ may be capable of clearing the

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cornea. We have seen cases where a large detachment clears up sometimes with a visual acuity of 20/20. This does not happen in bullous keratopathy,” he said.

He hypothesises that something in the host endothelium is determining whether the cornea is going to clear. The host endothelium in Fuchs’ might be lacking some factor they need, and when that factor is introduced with donor tissue, it functions in the normal way.

“If that is true then the whole concept of Fuchs' as dystrophy is called into question. In my opinion Fuchs' is not a dystrophy. It is a dysfunctional state of the cell. If we can reverse that state with cell injection or donor to the interior chamber, we may actually solve the problem,” added Dr Melles.

However, Dr Melles stopped short of calling DMET the next big step, noting that from the clinical point of view it takes much longer for cornea to clear when using the free-floating donor.

Patients might wait months to achieve good vision, while with DMEK patients are doing well after one month.

Another innovation, hemi-DMEK, originated as a way for use of donor tissue that was previously going to waste. HemiDMEK involves dissecting the entire Descemet’s membrane, then cutting it in half so that there are two half moon shaped grafts. The surgical technique is the same as DMEK, but requires a different technique at the eye bank. Visual acuity results are also similar to those seen with standard DMEK procedure, with the principal advantage being that one donor cornea can be used for two procedures.

Dr Melles emphasised that DMEK provides faster and better visual rehabilitation, and is associated with a similar pattern of reduction in endothelial cell density compared with traditional keratoplasty. The complication rates seen early on with DMEK were affected by the surgical learning curve, but it now appears that after proper training the rates of complications were significantly reduced to low levels.

“I always thought we could have done a better job of standardising the deep lamellar endothelial keratoplasty (DLEK) and Descemet’s stripping endothelial keratoplasty (DSEK) procedures. We are now standardising the way we teach DMEK. Students can learn the nuances at course taught at NIIOS and at conferences such as the ESCRS, and can follow up by watching many good videos available at NIIOS, YouTube and elsewhere. It is easy to learn and the learning curve is not too long. If you want to start with DMEK now you can learn and understand every step and learn every little detail.

“DMET may not really compete well with DMEK, but it may be a most interesting next step from a scientific point of view, because it opens the door to other treatment options, that is, not a ‘keratoplasty’ per se as we know it, but more towards a tissuedirective therapy,” said Dr Melles.

The first problem facing our field is that we have a tendency to produce more acronyms than Apple can produce apps Gerrit Melles MD, PhD

Gerrit Melles: melles@niios.com

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7th EuCornea Congress

OPENHAGEN2016

9–10 September Bella Center, Denmark Abstract Submission Deadline 15 March 2016

Corn

e

Eu

a

a

Eu

www.eucornea.org

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C o r n

European Society of Cornea and Ocular Surface Disease Specialists

CORNEA

PACK-CXL POTENTIAL Hope on the horizon for meeting the challenges of corneal infection treatment.

Cheryl Guttman Krader reports

P

hoto-activated chromophore for infectious keratitis corneal crosslinking (PACK-CXL) is showing promise as standalone treatment for early corneal ulcers and as an adjunct to antimicrobial treatment in more severe cases. However, it should not be used yet as a routine procedure, Farhad Hafezi MD, PhD told attendees at the 5th EuCornea Congress in Barcelona, Spain.

“Our vision is that PACK-CXL may become an early and first-line treatment for infectious keratitis. Perhaps with the development of a shortened treatment protocol, it may even be performed at the slit lamp by comprehensive ophthalmologists in the community,” said Dr Hafezi, Professor of Ophthalmology, University of Geneva, Switzerland and University of Southern California, Los Angeles, USA. However, PACK-CXL is not an established method. Whereas the published literature from 1997 until now includes 880 articles on CXL for keratoconus, there are only 50 articles on PACK-CXL. Additional research is needed in this field, and it is important that further development of PACK-CXL not be hampered by early reports of uncontrolled application leading to preventable complications, he emphasised.

Dalia G Said MD reviewed findings from a prospective clinical trial showing that PACK-CXL may be a safe and effective adjuvant for treating advanced infectious keratitis with corneal melting (Said DG, et al.

Ophthalmology. 2014;121(7):1377-1382). She also suggested PACK-CXL may be essential treatment for antimicrobial-resistant infectious keratitis, but Dr Said similarly identified a need for more research.

“Further study is needed to develop standardised protocols and to assess the response of different microorganisms in vivo,” said Dr Said, Research Institute of Ophthalmology, Cairo, Egypt, and University of Nottingham, UK. Dr Said also proposed that future research should evaluate whether repeating PACK-CXL can accelerate healing. “In our study of severe ulcers, there was a very rapid response to PACK-CXL, and the eyes improved dramatically during the first two to three weeks. Then, the improvement was more gradual, which raises the question: ‘Would an additional PACK-CXL be helpful?’” Dr Said explained.

EUROTIMES | FEBRUARY 2016

Courtesy of Farhad Hafezi MD, PhD

20

The participating sites of the Swiss multicentre PACK-CXL trial

FIRST-LINE INTERVENTION The name ‘PACK-CXL’ was adopted at the 9th CXL Congress in 2013 to replace ‘CXL for infectious keratitis’. Dr Hafezi noted the name refers to photo-activated chromophore rather than riboflavin, anticipating the introduction of new compounds that would increase the microbicidal efficacy currently achieved with riboflavin while allowing for a shorter treatment time.

In fact, a multicentre trial using an optimised photo-activator combining riboflavin with a novel chromophore in an accelerated treatment protocol is now under way. The study is being conducted at 17 sites in 15 countries and is comparing PACK-CXL to the current standard of care with antimicrobial therapy. It aims to enrol 252 eyes with an untreated corneal infiltrate or early superficial ulcer (<2mm, <300μm depth). Patients will be evaluated every 24 hours, and if PACK-CXL eyes show evidence of clinical deterioration they will be switched to conventional treatment. Time to re-epithelialisation of the cornea is being analysed as the primary endpoint.

“We are restricting the patients to those with early corneal ulcers, because findings from previous studies suggest that PACKCXL might be most beneficial before the depth of the ulcer exceeds the penetration possible with our current technical settings for CXL,” Dr Hafezi said.

The study aims to show that primary therapy with PACK-CXL will be at least as effective as topical antimicrobial treatment.

The results of a recently published animal study (Tal K et al. Cornea. 2015;34(10):1281-

1286) that compared the two modalities for the management of corneal ulcers induced by inoculation with methicillin-sensitive Staphylococcus aureus in rabbit eyes support that working hypothesis, Dr Hafezi said.

PACK-CXL FOR SEVERE CORNEAL ULCERS The study presented by Dr Said randomised 40 patients to PACK-CXL and medical treatment with an antimicrobial or to medical treatment alone. Isolated organisms included bacteria, fungi, mixed origin, and Acanthamoeba, although there was no growth in 25 per cent of cases.

At entry, the corneal ulcer was significantly larger in both width and length measurements in the PACK-CXL plus medication group compared with the controls. Nevertheless, mean time to healing was not significantly different between the two study groups (40 vs 46 days, respectively), and their final mean logMAR visual acuity was also similar (1.64 vs 1.67, respectively).

Safety was not significantly different in the PACK-CXL plus medication group. Patients in the study returned for daily follow-up until healing was complete, and Dr Said noted that hypopyon size in some eyes transiently increased early after PACK-CXL. “We believe this represents an inflammatory reaction to the dead microorganisms and the endotoxins and lipoproteins that are released,” she stated, similar to the “Jerish Herxheimer” reaction known from internal medicine.

Farhad Hafezi: fhafezi@elza-institute.com Dalia G Said: daliagsaid@yahoo.com

GLAUCOMA

LONG-TERM IOP CONTROL Trabecular bypass stent efficacy sustained for four years.

T

Roibeard O’hEineachain reports

he iStent® (Glaukos) trabecular bypass implant can provide glaucoma patients with long-term reductions in intraocular pressure (IOP) and the need for IOP-lowering medication, according to studies presented at the XXXIII Congress of the ESCRS in Barcelona, Spain.

“We have found the iStent to be a safe and effective treatment option through four years postoperative in patients with ocular hypertension or open-angle glaucoma,” said Tobias Neuhann MD, Marienplatz Eye Clinic, Munich, Germany.

Dr Neuhann presented a study involving 63 eyes of 41 patients with cataracts and glaucoma or ocular hypertension who underwent a combined micro-incision cataract surgery (MICS) and iStent implantation procedure. It showed that, throughout four years of follow-up, IOP was reduced by 33 per cent from preoperative medicated values, and the number of medications patients needed was reduced by 78 per cent.

Moreover, visual outcomes were good, with 95 per cent achieving a visual acuity of 20/40 or better and 68 per cent achieving 20/25 or better. The procedure also had none of the intra- or postoperative complications typically seen with conventional glaucoma surgeries, Dr Neuhann said.

The patients in the study had a mean age of 72.8 years and were evenly divided with regard to gender. Preoperatively they had a mean IOP of 24.1mmHg and were receiving a mean of 1.9 glaucoma medications, and all but three eyes were receiving at least one IOP-lowering medication, and 37 were receiving two or more.

All patients had cataracts requiring treatment. Their glaucomatous conditions included primary open-angle glaucoma in 39 eyes, pseudoexfoliation in 11 eyes, ocular hypertension in 10 eyes, secondary glaucoma in one eye and post-traumatic glaucoma in one eye.

Previous procedures the patients had undergone included laser peripheral iridotomy in four eyes, selective laser trabeculoplasty in eight eyes and argon laser trabeculoplasty in six eyes, and trabeculectomy in eight eyes.

In all eyes, Dr Neuhann performed MICS using a temporal clear incision and implantation of a single iStent through the same incision. The length of follow-up was 36 months in 41 eyes and 48 months in 34 eyes.

Throughout four years of follow-up, mean IOP remained at 18mmHg or below.

In addition, the mean number of IOPlowering medications fell from 1.9 at baseline to 0.1 at three months postoperative, and at four years remained low at 0.5 medications.

Furthermore, 58 per cent were medication free throughout Tobias Neuhann MD follow-up.

Implantation of a single iStent plus MICS is a sustained, safe and effective treatment for primary openangle glaucoma, pseudoexfoliation and ocular hypertension

Nonadherence to prescribed medications results in a greater risk for blindness in glaucoma patients George HH Beiko FRCSC Postoperatively, two patients were intolerant of topical and systemic therapy and underwent shunt surgery. Three patients underwent cyclophotocoagulation.

Dr Neuhann noted that the iStent devices are designed to bypass the trabeculum and allow drainage of aqueous from the anterior chamber directly into Schlemm’s canal. They are the smallest medical devices ever to have been implanted in the human body.

The original snorkel design used in the study has a length of 1.0mm, a height of 0.33mm, and weight of 60 micrograms. It is made of surgical grade heparin-coated titanium.

“Implantation of a single iStent plus MICS is a sustained, safe and effective treatment for primary open-angle glaucoma, pseudoexfoliation and ocular hypertension,” Dr Neuhann added.

LOWER IOPS LESS REDUCED The results of another study indicated that, in primary open-angle glaucoma patients with well-controlled IOP, the iStent may reduce the amount of medications needed to achieve that control but will not lower IOP significantly further, said George HH Beiko FRCSC, McMaster University and University of Toronto, Canada.

Dr Beiko retrospectively analysed the efficacy of the iStent in 49 of the first 100 patients to receive the devices at his centre, for whom three-year postoperative data was available. As in Dr Neuhann’s study, the patients all had visually significant cataracts, however their preoperative IOP was better controlled, with a mean value of 16.83mmHg. The Canadian researchers found that there was no statistically significant change in mean IOP at six months, 12 months, or three years, with respective values of 15.875mmHg, 16.42mmHg, and 16.531mmHg. However, there was a stable reduction in the number of medications patients required, from 1.6735 preoperatively to 1.0 at six months (p= 0.001) and 12 months (p=0.002), and 0.9184 at three years (p= 0.000).

In addition, the number of patients requiring no topical glaucoma medications rose from two at baseline to 22 at six months, and 28 at three years. Furthermore, the number of patients requiring two or more topical medications fell from 27 at baseline to 19 at three years.

Dr Beiko noted that reduction in the requirements for topical medications has considerable clinical relevance, given that studies have shown that only 56 per cent of patients use more than 75 per cent of the expected doses and only half of glaucoma patients refill their medication within six months of receiving their initial 90-day supply. Nonadherence to prescribed medications results in a greater risk for blindness in glaucoma patients, he added.

Tobias Neuhann: tneuhann@web.de George HH Beiko: george.beiko@sympatico.ca EUROTIMES | FEBRUARY 2016

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22

GLAUCOMA

DETERMINE

CALCULATE

CONFIRM

DETECTING PROGRESSION Consistency and critical analysis of perimetry results the key to determining progression rate. Roibeard O’hEineachain reports

V

isual field testing should be performed in a consistent manner with enough fields to determine the rate of progression over time, thereafter basing the frequency of testing on the rate detected, said Alfonso Anton MD, PhD at the XXXIII Congress of the ESCRS in Barcelona, Spain.

“Calculating the rate of progression is as important as identifying progression, as it allows an estimation of evolution of the disease and helps in making clinical decisions,” said Dr Anton, International University of Catalonia, Barcelona.

He presented a series of recommendations for optimal surveillance of visual field changes in patients with glaucoma. The first was that the visual fields used for comparison should be performed with the same perimeters and algorithms.

Therefore, the fields under review should have been performed with the same style perimetry, whether it be white-white, short wavelength automated perimetry (SWAP), frequency doubling technology (FDT) or others, using the same perimetry device, whether it be the Humphrey, Octopus or Topcon, and the same strategy for detecting change, whether it be Swedish interactive thresholding algorithm (SITA) – SITA Standard or SITA Fast – or tendency oriented perimetry (TOP).

He added that it is best to use strategies that are more reproducible and less variable, such as SITA Standard and TOP, while SITA Fast should be avoided. It is also important to exclude unreliable visual fields such as those with a false positive rate of more than 15 per cent, those with a learning effect and those with artefacts.

A minimum of four visual field tests is necessary to reliably determine a progression rate that could cause clinically significant visual loss, and some patients require many more, Dr Anton said. More frequent visual field testing is necessary in eyes where there is suspicion of progression. Eyes with greater visual field loss also require more frequent testing. He stressed that structural images should not be used as a substitute for visual fields, which provide the true clinical picture.

Variability of visual field tests over time greatly adds to the difficulty of detecting progression and determining its rate.

Variability increases towards the periphery and within deeper and in larger visual field defects.

“A greater variability increases the difficulty in detecting progression, therefore more follow-up visual fields are necessary,” Dr Anton said.

CONFIRM PROGRESSION When there is suspicion of progression, confirmation requires repeat visual field testing, and the change must be present in at least two consecutive visual fields.

The number of fields required to detect progression depends on the method used, the rate of progression, the degree of damage and variability. Once the progression has been confirmed and treatment modified accordingly, a new visual field baseline should be set, although prior visual fields should be retained in order to enable a global evaluation of the patient’s disease process.

It is also necessary to rule out other potential causes of changes in the visual field such as refractive errors, loss of transparency of the cornea, chorioretinal pathology or pathology of the visual

OPTIMAL FREQUENCY He emphasised that it is essential to obtain enough fields to first detect the rate of progression, and then on that basis determine the optimal frequency with which to perform follow-up visual field testing. The baseline visual fields should include at least two similar and reliable visual fields. The recommendation for initial follow-up visual field testing should be conducted six times over two years.

EUROTIMES | FEBRUARY 2016

pathway. Visual field defects not typical of glaucoma include the sudden development of large scotomas, scotomas that respect the vertical meridian and defects that cross the horizontal meridian.

At any visit, the present visual field should be compared with baseline, and the whole series of fields, at each point and with global indices. Manual methodical assessment is always available to all ophthalmologists, and the European Glaucoma Society (EGS) Guidelines has a set of criteria for the manual detection of new defects, deepening defects, extension of defects and diffuse depression.

However, although subjective assessment is useful, it is laborious, difficult and has low reproducibility. The EGS therefore recommends the use of automatic progression algorithms. For example, glaucoma progression analysis for SITA or Eye Suite, which compare observed change with expected variability and calculate rates of progression. Such rates quantify changes in the mean deviation or in the visual field index over time.

Dr Anton noted that event analysis is more sensitive in detecting progression initially.

However, trend analysis is more useful in determining the rate of progression, providing the patient underwent visual field testing more than six times over a period of more than six years.

“Interpret progression in the context of each patient. Revise results critically and consider the speed of progression, to identify rates that would imply functional impairment and adjust the frequency of testing. Make therapeutic decisions based on degree of damage, the patient’s age and the rate of progression,” Dr Anton added.

Alfonso Anton: anton@icrcat.com

A greater variability increases the difficulty in detecting progression, therefore more follow-up visual fields are necessary Alfonso Anton MD, PhD

1996–2016

1996 – 2016

Pictured following the announcement of the merger of the ESCRS and ASCRS journals are: front row (left to right) - Merrilee Obstbaum, Anne Kelman and Charles Kelman; back row - Dave Karcher, Steve Obstbaum, Michael Blumenthal, Robert Sinskey, Emanuel Rosen and Patrick Condon

SIGNIFICANT LANDMARK 2016 marks the 20th anniversary of the merger of the ASCRS and ESCRS journals and the first edition of EuroTimes, writes David Spalton

A

nniversaries provide an opportunity both to look back on how things were, and forwards to the future. In January 1996, the journals of the ASCRS and ESCRS merged, the result of a farsighted recognition by the two editors, Steve Obstbaum and Emanuel Rosen, that the sum of the whole would be greater than the two parts.

Time has proved what a good decision this was, with the JCRS, as it became, constantly establishing itself as the prime source of peer-reviewed information on cataract and refractive surgery.

GIFTED PIONEERS Although a successful journal relies heavily on the hard work of the editors, it also needs the commitment and enthusiasm of an editorial board. When I recently opened my January 1996 volume, I read a list of names all of whom are the most distinguished and gifted pioneers of cataract and refractive surgery.

It is a remarkably talented group and virtually all of them are still in practice and as active as ever 20 years later, which says something not only for longevity but also for the interest and enthusiasm cataract

and refractive surgery generates in all of us. Looking through the papers in the first issue from January 1996, one realises that although things have changed enormously we are still faced with much the same problems. This issue contains papers on surgically induced astigmatism, surgeon factors affecting biometry, posterior capsular opacification, corneal endothelial cell loss with phacoemulsification, the clinical evaluation of a refractive multifocal lens and two-year follow-up results of a new hydrophobic acrylic (AcrySof!) intraocular lens (IOL) – the authors concluding that “implantation of a soft acrylic IOL provides a safe and effective procedure for small incison cataract surgery”. These are all as relevant today as they were 20 years ago.

OBLIGATORY READING The monthly JCRS has established itself by quality and hard effort as obligatory reading as we are constantly challenged to keep up-to-date and to offer our patients the outcome they need and desire. One of the great things about the JCRS is that it is a good ‘read’, because not only is there the science, both clinical and relevant laboratory, but also the reviews, papers on techninique (enormously enhanced

by online video), the sometimes sharp correspondence (anterior segment surgeons are distinguished by their forthright opinions) and the consultation section of challenging cases which I like to read, make up my own mind about and then see how my management would compare with those of the review panel.

PEER-REVIEWED JCRS publishes carefully considered and peer-reviewed data, and by its very nature there is a time lag between submission and publication.

On the other hand EuroTimes, first published in February 1996, compliments this by up-to-the-minute reporting of events and meetings together with a wider and general overview of what is happening elsewhere in ophthalmology.

Our patients expect us to be familiar with what is happening in cornea, glaucoma or retina, either because it affects them or their friends and family.

Our lives would be duller and less interesting if we couldn’t keep abreast of what our colleagues are doing.

EuroTimes fills this gap and so becomes essential reading.

David Spalton is President of the ESCRS EUROTIMES | FEBRUARY 2016

I

II

1996 – 2016

WHATEVER HAPPENED TO?...

Past failures in vision correction reviewed with 20/20 hindsight. Roibeard O’hEineachain reports EUROTIMES | FEBRUARY 2016

1996 – 2016

uring the 20 years since the publication of the first issue of EuroTimes many new cataract and refractive technologies were introduced, often with much fanfare.

Some of them showed promise of fulfilling unmet needs and solving long vexing problems, only to fade from the headlines, sometimes for reasons not entirely clear.

ANGLE-SUPPORTED PHAKIC IOLS Angle-supported phakic intraocular lenses (IOLs) are a technology that have gone through several iterations, with different lens designs, such as the Vivarte, the ICARE and more recently, the AcrySof Cachet lens, only to be withdrawn from the market for the same reason, excessive endothelial cell loss. This begs the question of whether it is time to abandon anglesupported IOLs altogether.

Among those who believe that is indeed the case is Michael C Knorz MD, Universitätsmedizin Mannheim, Germany, who noted that although the concept was attractive originally because the lenses were easier to implant and the lack of need for an iridectomy, they failed because of the delicate balance needed between the haptic design and intraocular anatomy.

“The problem is three-fold: first, the proximity to the corneal endothelium. If the lens is too close, there will be progressive damage. Unlike iris-supported phakic IOLs, the proximity to the endothelium varies with size – if the IOL is slightly too large, the increased compression of the haptics moves it forward, which increases the likeliness of endothelial cell loss. Second, the problem of sizing leads to varying pressure on the angle. If

the pressure is too low, the IOL rotates. If it is too high, there is pupil ovalisation long-term.

Third, because the IOL position is unstable in a significant percentage, a toric design is not possible,” Dr Knorz said.

He added that angle-supported phakic IOLs have lost one of their advantages over posterior chamber phakic IOLs in that the current version of the Visian Implantable Collamer Lens (ICL, Staar Surgical) no longer requires an iridectomy.

Oliver Findl MD, Hanusch Hospital, Vienna, Austria, told EuroTimes that he is also of the opinion that angle-supported phakic IOLs are finished as a concept. He added that it was out of fear of endothelial cell loss that he never implanted any of the AcrySof Cachet lenses.

FIVE-YEAR RESULTS Thomas Kohnen MD, PhD, Goethe University, Frankfurt, Germany, takes a contrary view.

He told EuroTimes that he has recently submitted a manuscript to revisions in Ophthalmology, reviewing the five-year results in 515 patients implanted with the AcrySof Cachet lens. It showed that the annualised central corneal endothelial cell loss was only 1.5 per cent, amounting to only 7.5 per cent over five years. Greater amounts of endothelial cell loss are reported in studies with the Artisan lens, he pointed out.

“From my own experience, I see my patients and the implantations we have done with the AcrySof Cachet. I am sorry that it has been withdrawn from the market. But as regards the demise of anglesupported phakic IOLs, if they aren’t on the market then nobody will be implanting them,” he added.

NOT REALLY ACCOMMODATING IOLS Acommodating IOLs like the Crystalens (Bausch + Lomb), the HumanOptics IOL and the dual-

optic Synchrony IOL promised cataract patients a reduced dependency on reading glasses, and unlike multifocal IOLs do not compromise contrast sensitivity.

These lenses were designed to respond to accommodative forces of the ciliary contraction by moving the optic forward. However, several studies have failed to demonstrate that they actually provide any true accommodation.

“There isn’t any proof that any of these accommodating lenses work. In terms of the change in the axial position of the optic, the shift is very small, or even the wrong direction, and will also vary greatly between patients. There is no study that shows any actual dioptric change in refraction either,” Dr Findl told EuroTimes.

The Synchrony dual-optic IOL appeared to offer greater potential, because it required less movement of the optic to achieve an accommodative effect. Yet despite having completed a phase III FDA trial with the IOL, AMO have withdrawn the lens from the approval process.

“The Synchrony has not yet come to market and so far as I know there is a limited FDA trial and some very small case series here and there, but there is no proper randomised controlled trial that I know of that has been published.

Maybe it would have worked, I don't know. But at present there is no good data in the published results,” Dr Findl said.

He noted that IOL calculation can pose a particular difficulty with the Synchrony. On the other hand these lenses also pose safety issues.

For example, the Crystalens in its first designs, the AT45 and and the 5.0 had a lot of problems, such as the Z syndrome, which caused a very strong tilting of the optic in some cases. The HumanOptics 1CU had a very high posterior capsular opacification (PCO) rate and also had in-folding of their four small haptics in several cases.

EUROTIMES | FEBRUARY 2016

III

IV

1996 – 2016

I thought the LAL was a nice concept, but it is impractical to use Michael C Knorz MD

Richard Packard FRCS, Prince Charles Eye Unit, Windsor, UK, told EuroTimes that the lack of function in the lens is the reason why very few ophthalmic surgeons in Europe implant them.

However, he noted that the quest for a truly accommodating lens will continue until the goal has been achieved. Alcon is working with Google to help in the search for entrepreneurs to develop something which may well involve shape change of the lens and have an electronic basis.

LIGHT-ADJUSTABLE LENS Refractive surprises following cataract surgery have figured strongly as a problem in the history of IOLs and numerous features have been added to IOL design and biometric technology over the years to enhance the predictability of the procedure. In the early years of the millennium, a revolutionary concept was introduced, the light-adjustable lens (LAL, Calhoun Vision), which allowed for the postoperative adjustment of its dioptric power.

There have been a number of studies with the LAL which have shown that it enables a very considerable degree of accuracy within a quarter of a dioptre, and the lens appears close to being approved by the FDA. However, some factors may prove to be barriers to the wide use of the lens. For instance, the lens requires patients to wear special UV-blocking glasses for the weeks prior to the final lock-in of the adjusted refraction. It also requires the use of an expensive machine to perform what would be in most cases a small amount of refractive adjustment.

EUROTIMES | FEBRUARY 2016

“I thought the LAL was a nice concept, but it is impractical to use. First, patients have to wait too long and are inconvenienced too much by the glasses. Second, the expense of the additional procedures is too high, both regarding monetary and time requirements. I do not believe it will gain a significant market share,” said Dr Knorz.

Prof Kohnen agreed with that assessment and he pointed out that, even when the lens, the digital light delivery device and physicians experienced with the lens are available, patients still tend to find it an unappealing option. “I think this lens will fail because it's too complicated. We have access to the lens but find few patients opting for the lens,” he added.

LTK AND CONDUCTIVE KERATOPLASTY Laser thermal keratoplasty (LTK) for hyperopia was being strongly promoted and studied 20 years ago. The technique involved the use of a holmium laser to cause a contraction of the corneal tissue to increase the curvature of the central cornea. It was followed by conductive keratoplasty, for hyperopia and presbyopia, which employed the same principle.

Both techniques were granted FDA approval but both proved unsatisfactory and have now been abandoned.

“The main reason is lack of effect over time. Secondly, there were too many side effects. In all procedures which correct hyperopia, we have significant optical side effects due to the relatively small optical zone created. These side effects limit the amount of correction possible, and cause patient dissatisfaction,” said Dr Knorz.

“Another important reason is the availability of better techniques. The typical problem of the hyperopic patient is not just distance vision, but mainly near vision. None of the corneal procedures can address these two problems permanently, maybe with the exception of monovision techniques. An early cataract surgery or refractive lens exchange with a modern multifocal IOL or EDOF-IOL (extended depth of focus IOL), however, permanently solves the problem of distance and near glasses,” he added.

Corneal implants that were used for hyperopia produce scarring Thomas Kohnen MD, PhD

CORNEAL IMPLANTS FOR HYPEROPIA Various corneal implants have come and gone over the years. The early designs, like LTK, were designed as treatments for hyperopia. However, all had biocompatibility issues and proved not to be entirely reversible, in that patients would be left with worse vision in their treated eye than they started with after the implant has been removed.

“Corneal implants that were used for hyperopia produce scarring and opacity which, of course, is unacceptable. It is also not acceptable to have inlays which when taken out still leave patients with reduced visual acuity problems,” said Prof Kohnen.

Now there are a range of new corneal inlays for presbyopia, including the KAMRA Inlay (AcuFocus), the Flexivue Microlens™ (Presbia) and the Raindrop Near Vision Inlay (Revision Optics).

Dr Knorz noted that it is still too early to say if these new inlays will stand the test of time.

“Any implant in the cornea causes some scarring long-term.

That is also true for KAMRA and most likely for the other inlays. Will this affect vision? It is hard to tell but likely. What we do not know yet is how much change is acceptable.

The KAMRA definitely works in most patients, and once it performs as required the effect is lasting. It remains to be seen what the longterm fate will be,” he said.

Michael C Knorz: knorz@eyes.de Oliver Findl: oliver@findl.at Thomas Kohnen: kohnen@em.uni-frankfurt.de Richard Packard: mail@eyequack.vossnet.co.uk

TIMELINE Highlights from the last 20 years of EuroTimes, official news magazine of the ESCRS

1996 w Merger of European Journal of Implant and Refractive Surgery of the ESCRS and Journal of Cataract and Refractive Surgery of the ASCRS

1998 w Board of ESCRS co-opts Dr Thomas Kohnen and gives him special responsibility for facilitating links between the society and young resident ophthalmologists in training

First edition of Cataract and w Refractive Surgery EuroTimes is published

2000 w Sir Harold Ridley receives knighthood from Queen Elizabeth II w Foundation of EURETINA – European Retina, Macula and Vitreous Society

2004 Death of w

Charles Kelman, the father of phacoemulsification

2007 w Death of Michael Blumenthal, ESCRS president 1996-1997.

ESCRS launches the Michael Blumenthal Award for outstanding videos in his honour w EuroTimes wins Magazines Ireland Business to Business Magazine of the Year (more than 5,000 circulation)

2011

1997 1999 w Cataract and Refractive Surgery EuroTimes changes its name to EuroTimes w Harold Ridley awarded first ESCRS Grand Medal of Merit at XVII Congress of the ESCRS in Vienna, Austria

2002 w Work begins on ESCRS Strategic Plan, under direction of then president of the society Ulf Stenevi

2005 w ESCRS delegation meets with European Commission and European Union officials to propose that the society should assume a leading role in helping the EU shape the future of ophthalmic surgery

w First World Congress of Paediatric Ophthalmology and Strabismus (WCPOS) held in Barcelona, Spain in conjunction with XXVII Congress of the ESCRS

w Launch of ESCRS Endophthalmitis Trial, the largest multicentre controlled trial ever undertaken in ophthalmology worldwide w Ophthalmologists in certain countries forced to suspend non-essential services following worst outbreak of Severe Acute Respiratory Syndrome (SARS) reported outside Asia

w EuroTimes wins Magazines Ireland Business to Business Magazine of the Year (more than 5,000 circulation)

2014 2016 w 20th ESCRS Winter

Meeting convenes in Athens, Greece

w EuroTimes launches new app for download for ophthalmologists. This initiative is part of the magazine’s ongoing development of online services, including its website www.eurotimes.org and its social media platforms on Facebook and Twitter

w Death of John Henahan, editor of EuroTimes 1996-2001 w First EURETINA Congress held in Hamburg, Germany

2006

w ESCRS publishes EuroTimes India and EuroTimes China magazines and introduces EuroTimes Russia website

2008 2010 w New service for Turkish ophthalmologists with launch of EuroTimes Turkey website w Establishment of ESCRS Observership Programme for young ophthalmologists who are starting their surgical training or already in surgical training w ESCRS announces a new initiative to support Orbis International and Oxfam with their work in the developing world w EuroTimes wins Magazines Ireland Designer of the Year Award

w Introduction of The European Registry of Quality Outcomes for Cataract & Refractive Surgery (EUREQUO) for the development of a European registry of surgical outcomes in cataract and refractive surgery w First Practice Development Workshops, teaching ophthalmologists business skills, held during the XXVI Congress of the ESCRS in Berlin, Germany

2012

w ESCRS establishes Young Ophthalmologists Committee and online e-learning initiative iLearn w Emanuel Rosen, then chairman of the ESCRS Publications Committee, awarded Grand Medal of Merit at XXIX Congress of the ESCRS in Vienna, Austria

2001

2003

2009 w EuCornea, a new subspecialty organisation for cornea and ocular surface disease specialists, is launched during the XXVII Congress of the ESCRS

w First ESCRS Winter Meeting, dedicated to refractive surgery, held in Madrid, Spain

2013 w ESCRS publishes European Society of Cataract & Refractive Surgeons – A History, telling the story of the society from 1982 to 2012 w Death of Joseph Colin, former board member of ESCRS

w Signing of a research funding contract for the Prevention of Macular Edema (PreMED) after cataract surgery study w EuroTimes wins Magazines Ireland Front Cover of the Year Award

2015

w The European Alliance for Vision Research and Ophthalmology (EU-EYE), a non-profit pan-European advocacy organisation with representatives from eight of Europe’s ophthalmology societies, including the ESCRS, is officially launched at XXXIII Congress of the ESCRS in Barcelona w EuroTimes wins Magazines Ireland Business to Business Magazine of the Year (more than 5,000 circulation)

WINNER e B2B Magazin 5 1 0 2 r a e of the Y 0 (more than 5,00 circulation)

THE

TO BE REACH

42,957

*

CUSTOMERS IN OVER 150 COUNTRIES WITH YOUR AD Advertise with the highest audited circulation for any ophthalmic news magazine in Europe 59 per cent of our readers surveyed in an independent research survey have decision-making power when it comes to the purchase of surgical/medical equipment or supplies. A further 20 per cent are usually consulted before a final decision is made**

* Average net circulation for the 10 issues circulated between 1 January 2014 and 31 December 2014. See www.abc.org.uk ** Results from the

EuroTimes Readership Study 2011

RETINA

CHECK THE MEDICATION Research underscores need for detection of potentially toxic dosing. Cheryl Guttman Krader reports

O

phthalmologists who care for patients being treated with hydroxychloroquine (Plaquenil) should remember to check the patient’s medication dose in addition to checking their eyes, said researchers from Bronx-Lebanon Hospital Center, Bronx, New York, at the 2015 annual meeting of the Association for Research in Vision and Ophthalmology in Denver, USA. They reached this conclusion after examining records of patients seen in the outpatient service between December 2008 and May 2014. The researchers identified 643 patients who had been prescribed hydroxychloroquine. Daily doses for each patient were compared to the American Academy of Ophthalmology recommendations that state a hydroxychloroquine dose of 400mg/day is acceptable, except for persons of short stature who should receive <6.5mg/kg ideal body weight/day (Ophthalmology. 2011;118:415–422).

The review found 86 per cent of patients were receiving a daily dose of 400mg. However, calculations of weight-based doses showed 70 per cent of patients were being treated with a daily dose >6.5mg/kg of ideal body weight, and the dose in almost one-fourth of those patients (16 per cent overall) exceeded the 6.5mg/kg threshold by more than 30 per cent.

“Tall and average height people are easily within the safe range of 6.5mg/kg ideal body weight/day. However, one has to be more careful in short stature people because the standard 400mg/day dose may be too much,” said Jonathan Levine MD, a retina specialist.

“When in doubt, pull out the calculator, and remember that unlike other medications for which dosing is based on actual body weight, hydroxychloroquine is dosed according to ideal body weight,” he advised.

DOSING PRESCRIPTION Jing Grace Wang DO, PhD noted that the dosing decision for each patient is ultimately up to the judgment of the prescribing physician, taking into account the risks and benefits of different dosing levels.

“However, if it is determined that a higher dose is needed, patients need to be educated about the risk of macular toxicity and the importance of ophthalmologic follow-up,” she said.

Dr Wang acknowledged that dosing flexibility is limited with hydroxychloroquine since the medication is only available as a 200mg tablet. When 400mg/day is too much, patients can be prescribed 300mg/day, which requires splitting a tablet, or they can take 400mg/day and 200mg/ day on alternate days. “Success with those more complex regimens requires good patient education,” said Dr Wang.

She also noted that use of the electronic medical record system at the Bronx-Lebanon Hospital has facilitated effective communication about retinopathy status and dosing concerns between the department of ophthalmology and physicians prescribing hydroxychloroquine.

Jonathan Levine: jlevine1@bronxleb.org Jing Grace Wang: jinggracewang@gmail.com EUROTIMES | FEBRUARY 2016

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24

RETINA

LOGICAL APPROACH Psychological factors underestimated in retinal detachment management.

T

he complexities of human psychology play a far more important role in the decisionmaking process concerning key questions of retinal detachment (RD) management than we might imagine, Bill Aylward FRCS, FRCOphth, told delegates attending his Kreissig Lecture at the 15th EURETINA Congress in Nice, France.

In a wide-ranging lecture on “A logical approach to retinal detachment”, Dr Aylward, past president of EURETINA, touched on topics as diverse as scurvy, mathematics, psychology and the flawed nature of current scientific tools in explaining why it is so difficult to resolve some of the more intractable questions surrounding RD. The questions to which Dr Aylward referred included: ‘Does laser treatment to lattice degeneration reduce the lifetime risk of RD?’; ‘What is the best treatment for rhegmatogenous retinal detachment (RRD)?’; and ‘Does shaving the vitreous base increase the success rate of vitrectomy for RRD?’ These questions are not resolved for a variety of reasons, including the subject matter, tools and human and psychological factors, said Dr Aylward, UK. In terms of scientific tools, Dr Aylward cited a scale of evidence starting with the “gold standard” of randomised controlled trials, followed by cohort studies, case control studies, case series, and expert opinion.

Taking the example of lattice degeneration and whether laser treatment might reduce the lifetime risk of RD, Dr Aylward said that while this question could be resolved with a randomised clinical trial, in reality it is not so easy.

“We know that the annual incidence of RD is 0.01 per cent, and if we assume that the laser works and cuts the detachment rate by 50 per cent, the number of patients required is over 7,000 in each arm of the trial. And because we are treating young people, we need to wait until they have had their posterior vitreous detachment, so we would need a 40-year follow-up. Clearly this is never going to happen,” he said.

BEST TREATMENT Turning to the best treatment for RD, Dr Aylward said that while everyone agrees on the mechanisms and surgical principles concerning RD, there is still wide divergence on the best methods to achieve this.

“The biggest determinant is where the surgeon trained – so it will be vitrectomy in the UK or scleral buckle in the USA, and so forth,” he said.

EUROTIMES | FEBRUARY 2016

Dermot McGrath reports

Bill Aylward (left), who delivered the Kreissig Lecture, with Ingrid Kreissig at the 15th EURETINA Congress in Nice

A study of surgical trends for RD in the UK in 2001 showed vitrectomy growing in popularity, said Dr Aylward, “not for any scientific reason but for a number of practical reasons, specifically facility with the procedure, internal searching and wide-angle viewing systems which appeared to make the surgery easier.”

In 2007, a robust study by Heimann et al comparing scleral buckling versus primary vitrectomy in RRD concluded that there was better vision with buckling in phakic eyes and better primary success with vitrectomy in pseudophakic eyes.

“Did that make a difference in clinical practice? Well we see in a 2015 survey from Moorfields Eye Hospital that vitrectomy is still far more popular than scleral buckling. So there is a general problem that randomised trials do not always influence practice,” he said.

To illustrate the point, Dr Aylward cited James Lind’s 1753 study on scurvy among sailors – the first ever recorded randomised controlled trial (RCT) – which showed the beneficial effect of citrus fruits in preventing the disease. The Royal Navy ignored Lind’s findings for 42 years, he said.

Dr Aylward said more expertise-based RCTs were needed in the future, as opposed to clinical trials where the same surgeon performs a less preferred surgical option on half the patients.

Statistics, a discipline which is “difficult and non-intuitive”, should also be treated with caution.

REGISTRIES HELP Registries help in removing some of the known biases from the data, said Dr Aylward, with advances in technology meaning that prospective collection of detailed clinical data is now possible.

“This deals with known biases, though not unknown ones. The output is not as good as an RCT, but better than nothing,” he said.

Psychology also plays an important role in the decisions that physicians make in terms of treatment, said Dr Aylward.

“I am glad to say that psychology is now being taught at some medical schools. I think we also need a healthy scepticism about our beliefs and training, and need to apply a little bit more logic to our thinking,” he said.

Dr Aylward cited issues such as confirmation bias – the tendency to search for, interpret, favour and recall information in a way that confirms one’s beliefs or hypothesis – as posing a problem for logical decision-making. Similarly, physicians should be aware of the “sunk cost fallacy” by which future decisions are inappropriately influenced by past investment.

Bill Aylward: bill@aylwards.co.uk The Kreissig Award was established in 2003 in recognition of the immense contribution of Prof Ingrid Kreissig to ophthalmic training and research, particularly in the field of retina

8â&#x20AC;&#x201C;11 September 2016

COPENHAGEN 16th EURETINA Congress

Bella Center, Denmark

www.euretina.org

RETINA

VAMPIRE PROJECT Software application enables efficient, semi-automatic quantification of retinal vessel properties. Dermot McGrath reports

T

here is mounting evidence that the retinal vasculature and its changes can provide biomarkers for a number of high-prevalence conditions, both systemic and eye-related, which can be observed inexpensively in vivo by the latest imaging technologies, Emanuele Trucco PhD, FRSA told delegates attending the 15th EURETINA Congress in Nice, France.

Huge strides have already been made towards identifying and categorising such biomarkers, thanks to specialised software created by Prof Trucco and his team of co-workers at the Universities of Edinburgh, led by Dr Tom MacGillivray, and Dundee, UK, together with input from other research centres in ltaly, Singapore, Australia, Japan and the USA. Known as VAMPIRE (Vascular Assessment and Measurement Platform for Images of the REtina), the software application enables efficient, semi-automatic quantification of retinal vessel properties with large collections of fundus camera images. Pathological signs and changes in the retinal vasculature may reflect similar processes occurring elsewhere, e.g in the cardiovascular system and the brain. Thus the retina represents an accessible site for the study of systemic and neurological disease.

“The system aims to provide efficient and reliable detection of retinal landmarks such as optic disc, retinal zones, and main vasculature, and quantify key parameters used frequently in investigative studies such as vessel width, vessel branching coefficients, fractal dimension and tortuosity. VAMPIRE can compute such measures efficiently, and provide researchers with a large number of quantitative parameters,” Prof Trucco told EuroTimes.

Non-invasive observation of the retinal vasculature is possible with a fundus camera or scanning laser ophthalmoscope, while optical coherence tomography (OCT)

SLO image with highlighted vascular trees traced by VAMPIRE software

We are currently adapting VAMPIRE for fundus images in order to include more measurements...

Emanuele Trucco PhD, FRSA reveals the tissue layers, which permits study of the structure and pathology of the nerve fibre layer. VAMPIRE work involves all of these modalities.

The ultimate goal is to enable efficient quantitative analysis of large collections of retinal images acquired from multiple instruments. The software has already been used to analyse more than 10,000 images in studies investigating retinal biomarkers for cardiovascular disease, diabetes, stroke, multiple sclerosis, cerebral malaria, Alzheimer’s and age-related diseases.

Prof Trucco noted that biomarkers are a key element in identifying abnormalities that may mark the early onset of disease. “The purpose of the studies using VAMPIRE so far has been to find associations between retinal vasculature changes and specific diseases, in order to contribute to defining the constellation of signs that may warn about the insurgence of a disease. The diseases considered are such that early intervention, triggered by early detection, can delay the progress of the disease, maintain quality of life for the patient, and limit costs to carers and national health services,” he said.

PUSHING BOUNDARIES

The VAMPIRE 3.1 interface, showing a fundus camera image being processed

EUROTIMES | FEBRUARY 2016

While a lot has been achieved already, VAMPIRE has the potential to exploit ongoing advances in imaging technology and computational power to continue

pushing the boundaries in predictive medicine, added Prof Trucco.

“We are currently adapting VAMPIRE for fundus images in order to include more measurements, and incorporating analysis of OCT images, especially the very recent technique of OCT angiography, capable of revealing vascular beds never seen before,” he said.

As Prof Trucco observes, the retinal vasculature is just one aspect of a complex system and needs to be considered in conjunction with other patient data in order to maximise its true value.

“It is arguable that the retinal fibre layer, for instance, may also hold valuable information, and we are starting to work on this, beyond its current role in assessing the early risk of glaucoma. I believe that the real treasure trove for early prediction in biomarker research lies in considering the retina together with any other data available about a patient.

"This is the direction that predictive medicine is taking, linking interdisciplinary areas such as big data (analytics), creating increasingly large repositories of clinical data for research, continuously improving image analysis algorithms and software, availability of high-throughput computing platforms such as the cloud, and even crowdsourcing,” he said.

Emanuele Trucco: e.trucco@dundee.ac.uk

Courtesy of VAMPIRE Project Team

26

OCULAR

ANTIBIOTIC RESISTANCE Growing concern over antibiotic resistance, but new developments may help. Leigh Spielberg MD reports

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elivering the event’s keynote address to a full auditorium at the 7th International Conference on Ocular Infections in Barcelona, Spain, Yehuda Carmeli MD, MPH, Professor of Internal Medicine and Infectious Diseases at Tel Aviv University, Israel, began his presentation with a photo of the now-famous petri dish of penicillium inhibiting the growth of bacterial colonies.

That was in 1928, nearly a century ago, and many millions of lives have since been improved and even saved due to treatment with penicillin. However, the development of antibiotic resistance rapidly became a problem. This was first seen in hospitals, followed later by the development of resistance in the community.

“Resistance represents a mismatch between treatment and susceptibility, leading to increased cost, morbidity and a two-fold increase in mortality as compared to infection with a susceptible strain. It causes a delay in adequate therapy, and the use of clinically less effective agents leads to worse outcomes,” said Dr Carmeli.

WHAT CAN BE DONE? “It is widely known that there is a strong correlation between indiscriminate antibiotic use and microbial resistance, with countries like The Netherlands at the forefront of careful and disciplined antibiotic policy,” said Dr Carmeli.

Striking graphs demonstrated the differences between countries regarding total antibiotic use and penicillinnonsusceptible S. pneumoniae.

Changes can be made. Requiring prior authorisation for selected antimicrobials impedes their indiscriminate use, decreasing resistance rates. Decreasing veterinary medicine use on farms might do the same, as might screening patients from high prevalence areas so that they may be treated before getting the chance to infect others.

With the knowledge that β-lactamase enzymes are the main mechanism of

resistance to penicillin, via their hydrolysis of antibiotic molecules, nearly a thousand variants have been identified, with the goal of developing new drugs that avoid this enzymatic destruction.

Dr Carmeli also discussed the changing epidemiology of resistance throughout the world, tracking the rapid spread of resistant strains between countries.

Besides well-known organisms like MRSA, others were mentioned: multidrug resistant enterobacteriaceae and bacteremia due to extended-spectrum β-lactamase (ESBL)-producing Escherichia coli, and carbapenem-resistant Klebsiella pneumoniae and Acinetobacter baumannii.

Outcomes for those infected are not good.

These so-called “superbugs” have even made it into the news media.

A ray of hope was provided at the end of Dr Carmeli’s presentation. Nationwide interventions can help decrease the incidence of infections with resistant strains, particularly those of nosocomial origin. Countering this good news is the fact that pharmaceutical companies have been decreasing their involvement in antibacterial development.

“There was a steady rise of active corporate antibacterial programmes between the 1940s and the late 1980s. But since then, and especially over the past 15 years, there has been a steady decline. Since 1996, only 14 companies have entered the market while 36 have exited, leading to a significant net decrease in the efforts to develop new and innovative antibiotics,” noted Dr Carmeli.

Solutions must involve enhanced infection control, antibiotic stewardship and sustained focus on drug development, Dr Carmeli concluded.

“But what about ophthalmic drugs?” asked David G Hwang MD, FACS, Professor and Vice Chair of Ophthalmology at the University of California, San Francisco, USA, who spoke next on the topic of ophthalmic drug development.

“Ophthalmic drug development has been dominated by two decades of fluoroquinolone development. Azithromycin

It is widely known that there is a strong correlation between indiscriminate antibiotic use and microbial resistance...

Yehuda Carmeli MD, MPH

is the only other non-fluoroquinolone to gain FDA approval in the past 20 years, and besifloxacin was the last non-combination antimicrobial to be approved, in 2009. This represents a complete drug development void since 2009,” he emphasised.

There are several major unmet needs in ophthalmology, he stressed. These include treatment for fluoroquinolone-resistant strains; antibiotics for methicillin-resistant staphylococci; and formulations of existing antimicrobials intended specifically for topical, intracameral and intravitreal use.

But development hurdles continue to hamper progress.

“The small size of the ophthalmic antibiotic market relative to development costs is a big problem, as are ocular toxicity testing requirements and ophthalmic formulation issues. For example, a number of antimicrobials designed to be reconstituted for immediate parenteral use cannot be used for commercial ophthalmic preparations, because when stored in aqueous solution at room temperature, they are relatively unstable over weeks to months of shelf life. Further, many newly developed antibiotic agents are narrow, second- or third-line agents created for specific, nonocular targets,” said Dr Hwang.

Dr Hwang remained hopeful, however, because of the recent incentivisation of drug development. The Generating Antibiotics Incentives Now (GAIN) Act of the US Congress (2012) has called for an accelerated FDA approval process for new drugs and a five-year extension of patents for so-called qualified infectious disease products. This has already led to FDA approval of eight new antimicrobials since 2010, although none has yet been developed for ophthalmic use.

“Can we incentivise ophthalmic drug development similarly?” asked Dr Hwang. He stressed the need for a better development path for prophylaxis indications, as these are more commonly needed in ophthalmology than treatment indications. Another suggestion is the granting of an extension of patent exclusivity to the parent compound for approval of non-systemic (in this case, ophthalmic) formulations.

“We need integrated antimicrobial management policies if we are to avoid a dystopian future of massive antibiotic resistance,” concluded Dr Hwang.

Yehuda Carmeli: yehudac@tlvmc.gov.il David G Hwang: david.hwang@ucsf.edu EUROTIMES | FEBRUARY 2016

27

28

PAEDIATRIC OPHTHALMOLOGY

PAEDIATRIC CATARACT Femto-assisted capsulotomies are safe and effective in paediatric cataracts. Dermot McGrath reports

F

emtosecond laser-assisted anterior and posterior capsulotomies are safe and effective techniques that can greatly enhance the quality of congenital cataract surgery in children, Irina Trifanenkova MD told delegates attending the 3rd World Congress of Paediatric Ophthalmology and Strabismus in Barcelona, Spain. â&#x20AC;&#x153;There are a lot of advantages to using a femtosecond laser to create capsulotomies in paediatric cases. There is a decrease in surgery time, greater control of the surgical steps, reduction of intraocular lens manipulation and a reduction of intraoperative and postoperative complications with the creation of precise, perfectly-centred and round anterior and posterior capsulotomies,â&#x20AC;? she said.

Dr Trifanenkova, S Fyodorov Eye Microsurgery, Federal State Institution, Kaluga, Russian Federation, noted that congenital cataract remains one of the most common causes of childhood blindness worldwide and early surgical intervention is essential to prevent visual loss.

She reported a case series of femtosecond laser-assisted capsulotomies performed in 12 eyes of eight children aged from three months to seven years with congenital cataract. Anterior capsulotomy only was performed in eight eyes of four patients: two with swelling cataract, one with nuclear cataract and one with anterior capsule fibrosis. The remaining four patients received both anterior and posterior capsulotomies because of posterior capsule fibrosis, she explained.

FLUID-FILLED INTERFACE Dr Trifanenkova said that the Femto LDV Z8 laser (Ziemer) offers a fluid-filled interface which allows the surgeon to easily dock EUROTIMES | FEBRUARY 2016

There are a lot of advantages to using a femtosecond laser to create capsulotomies in paediatric cases Irina Trifanenkova MD

the laser to the eye for anterior capsulotomy. Using very low energy of less than 1.0mj a gentle resection is possible in order to minimise risks and side effects in creating a capsulotomy of 2.5-4.5mm in diameter. She noted that surgeons should be aware that anterior capsulotomy size has a tendency to increase after laser treatment due to the high elasticity of the capsule in young patients, so this needs to be factored into the surgical planning.

The integrated 3D optical coherence tomography system also allows easy visualisation of the posterior capsule in creating well-centred central posterior capsulotomies of 2.5-3.5mm in diameter. All of the surgeries in this series were performed without any complications and the anterior and the posterior capsule disks were removed by aspiration without any capsular tears.

All the patients had postoperative period without complications and obtained excellent visual acuity at the end of the follow-up, she said.

Summing up, Dr Trifanenkova said that the femtosecond laser provided a safe and effective means of creating anterior and posterior capsulotomies of perfect diameter and circularity in these challenging paediatric patients.

Irina Trifanenkova: nauka@eye-kaluga.com

PAEDIATRIC OPHTHALMOLOGY

Devices preventing PCO, interchangeable optics may improve safety. Howard Larkin reports

C

lear lens exchange (CLE) may be indicated for some children, but posterior capsular opacification (PCO) and refractive changes as young eyes grow are challenges.

Devices and techniques that prevent PCO, and intraocular lenses (IOLs) with interchangeable optics could make the procedure safer, Ioannis G Pallikaris MD, PhD told the 2015 American Society of Cataract and Refractive Surgery Symposium in San Diego, USA. Generally, clear lens extraction is considered for myopia of -10 dioptres or more, and hyperopia of +7 dioptres or more, Prof Pallikaris noted. In children, CLE may be indicated for severe anisometropia or ametropia with neurobehavioural disorders, peripheral lens opacities despite a clear central crystalline lens, and spectacle and contact lens intolerance. It may also be useful to reduce elevated pressure in eyes with high hyperopia and short axial length, and to treat lenticular disorders including Marfan’s syndrome, spherophakia and lenticonus.

CLE contraindications include retinal disease, with retinal detachment a higher risk with high myopia, as well as glaucoma with visual field loss and amblyopia, Prof Pallikaris said. Systemic conditions including diabetes with eye signs or inadequate control, Ioannis G Pallikaris rheumatoid arthritis with Sjogren syndrome, pathologic dry eye, lupus and AIDS are also contraindications. Patients medicated for clinical depression may also be poor candidates as they may not respond well to unintended outcomes or complications, he added.

CLE advantages include leaving the cornea mostly untouched and eliminating future cataracts, Prof Pallikaris noted. However, in children PCO is almost a certainty and refractive changes will occur as the eye grows.

PREVENT COMPLICATIONS Several approaches may help prevent these complications, Prof Pallikaris said. These include primary posterior capsulorhexis, and a peripheral capsule reconstructor he designed that may help prevent PCO by creating a barrier to cell proliferation across the posterior capsule. The device has been successfully tested with three-piece and one-piece conventional lenses, as well as the Tassignon bag-in-lens.

“All of these are very well centred on this peripheral ring, and is easy to rotate, which is very important with a toric IOL.” Refractive stability may be enhanced with a multicomponent IOL with a base rear optic inside the bag and a removable second optic outside the bag, Prof Pallikaris said. This would make it easier to exchange the optic as the patient’s prescription changes, negating the need to completely explant the lens from the fibrotic capsule. The concept has been tested successfully in Prof Pallikaris’ Institute of Vision and Optics at the University of Crete, Greece, he said.

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Ioannis G Pallikaris: pallikaris@dunyagoz.com EUROTIMES | FEBRUARY 2016

29

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INNOVATION

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NANOTECHNOLOGY ew nanotechnology drug delivery systems offer the potential to improve therapeutic efficacy, enhance patient comfort and compliance and reduce side effects in the treatment of a wide range of ocular conditions, Marc Ramis Castelltort PhD told delegates attending the XXXIII Congress of the ESCRS in Barcelona, Spain.

“What we are trying to do in the nanotechnology field is to increase the level of selected molecules in a specific region to improve the payload efficacy of the drug and reduce related side effects. In most cases, we use a molecule that is able to target specific tissue. In oncology, for example, CD44 is a receptor expressed in different solid tumours, so we use nanoparticles that actively target CD44,” he said.

There is no gold standard nanoparticle for drug delivery systems, with each nanoparticle possessing specific physicochemical properties that make them unique for a specific application, explained Dr Ramis Castelltort, CEO of Tech and Business Innovation, Spain.

“We cannot use a single particle for delivering any kind of drug or for any kind of clinical indication. Instead we have different families of nanomaterials that can be used in drug delivery such as inorganic, polymeric, solid lipid nanoparticles, nanocrystals, nanotubes, dendrimers, and so forth. Every year we see the emergence of new types of nanomaterials that could have potential use in drug delivery,” he said.

DIFFERENT PROPERTIES Dr Ramis Castelltort illustrated the point with reference to gold nanoparticles.

“Experimenting with the size and shape of these nanoparticles enables us to obtain different properties. For instance, gold nanospheres are very good at penetrating tumorous cells, so that they can be incorporated in the drug delivery coating to improve uptake in the tumorous cells.

Gold nanorods have been found to change their shape after excitation with intense pulsed laser irradiation, and nanoshells

Courtesy of UPV academics: Prof Jose Ramón Murguía and Ramón Martinez Máñez

N

Nanoparticles offer enhanced payload efficiency for ocular drug delivery. Dermot McGrath reports

are particularly useful in imaging applications,” he said.

The problem with conventional drug delivery systems is that ophthalmic formulations do not maintain therapeutic drug concentration in the target tissues for a long duration, due to physiological and anatomical eye barriers, explained Dr Ramis Castelltort. “With nanoparticles, we want to improve the current payload route of administration to the anterior segment and increase drug-corneal residence time. With corneal and stromal barriers, current payloads reach the designated cells only in a very low percentage,” he said.

One possible solution in glaucoma has been to use intraocular implants comprised of a blend of prostaglandin analogues, polylactic acid and/or polylactic-co-glycolic acid (PLGA) for the controlled release of drugs.

Nevertheless, while nanoparticles have the potential to improve ocular tissue exposure from topical administration, they still need to penetrate the ocular mucus layer which serves to protect the eye from allergens, pathogens and foreign bodies, said Dr Ramis Castelltort.

Experimenting with the size and shape of these nanoparticles enables us to obtain different properties Marc Ramis Castelltort PhD

One approach has been to use nanoparticles to develop mucuspenetrating formulations. In preclinical trials of one such drug delivery system, loteprednol etabonate, a corticosteroid specifically designed for ophthalmic inflammatory indications but known to have limited penetration into ocular tissues after topical delivery, was found to have a fourfold increase in rabbit corneas, he said.

Another interesting technique has been to use a nanowafer, a small transparent circular disc that contains arrays of drug-loaded nanoreservoirs, to treat corneal neovascularisation (CNV), said Dr Ramis Castelltort.

In a murine ocular burn model, the slow release of axitinib from the nanowafer increased the drug residence time on the ocular surface and its subsequent absorption into the surrounding ocular tissue. The study concluded that axitinib nanowafer administered once a day was therapeutically twice as effective in the treatment of CNV as axitinib delivered twice a day by topical eye drops.

Many other nanoparticle delivery vehicles are currently being investigated for ocular use, said Dr Ramis Castelltort, including polymeric nanoparticles for ocular delivery of atropine, dendrimerdexamethasone therapy for the treatment of corneal inflammation, antibiotic delivery through DNA-based nanoparticles, and muco-adhesive nanoparticles to enhance treatment of experimental dry eye.

Marc Ramis Castelltort: mramis@tbinnovation.com EUROTIMES | FEBRUARY 2016

RESEARCH

THE PERFECT IMPERFECTION A changing understanding of emmetropia calls for a revised definition, writes Ioannis G Pallikaris MD, PhD

T

he goal of most forms of cataract and refractive surgery is the achievement of emmetropia, but the very definition of the term “emmetropia” may have to change, in light of the increasing understanding of the complex interaction between the static and dynamic components of the human optical system and their subtler impacts on vision.

British and American dictionaries define emmetropia as the normal refractive condition of the eye when accommodation is relaxed and parallel rays are focused on the retina. What their definitions leave open to interpretation is whether “normal refractive condition” means a condition where all parallel rays of light, central and peripheral, are brought accurately to a focus upon the retina, and also whether such a questionably perfect refractive condition will also be the most satisfying for the individual.

THE MEANING OF THE WORD When considering a term’s definition it can often be helpful to break down the literal meaning of the term, as Antisthenes (ca 445-365 BC) stated: “The principle of wisdom lies in the study of words.”

The term emmetropia is a neoLatin term deriving from the Greek “émmetros”, meaning “on measure”, with the suffix “-opia” meaning “pertaining to the eye or vision”. The Greek metrparticle of the word, as is used in various ways by the ancient authors, can be seen EUROTIMES | FEBRUARY 2016

Plainis et al, 2005, Courtesy of Ioannis G Pallikaris MD, PhD

32

in Plato’s quotation of Protagoras in his Theaetetus: “Antropos metron”, “Man is the measure (of all things).”

Or as Cleobulus stated, according to Diogenes Laërtius: “Metron Ariston”, “Moderation is best.”

The term “metron” has also been used by the Greek philosophers since the ancient times to describe certain types of imperfection.

The application of that principle is evident in the architecture of the the Parthenon, which was built in such a way that, upon entering the temple, one

would have a perfect anamorphic view of the building’s dimensions. The columns appeared to be straight and parallel and the aetoma arranged in a perfect parallelogram.

But, in fact this was an ingenious optical illusion, achieved through the use of what might be considered imperfections, in construction terms. The columns were oval in shape, and the space between them on all sides of the chamber decreased from the centre to the periphery, and the columns were not not aligned in parallel but with a subtle curvature. Together these refinements served to counteract the

RESEARCH naturally-occurring optical illusion that causes long parallel lines to appear to sag in the middle.

PURPOSEFUL IMPERFECTIONS Vision research has revealed similarly purposeful imperfections in the human optical system, and show that it consists of both static and dynamic components.

The challenge of emmetropia is likewise multifactorial in nature.

Among the static elements of the eye’s optical system is miosis, which increases the focal range at which a reasonable image quality can be achieved. Studies show that although miosis increases in response to accommodation in a fairly linear fashion, miosis also occurs independently of accommodation.

Other static components of human vision include bifocal elements, which divide the focus into two disparate peaks, each with reduced image contrast, and aberrations (in particular spherical aberration) which can contribute to increased depth of focus at the expense of image quality.

Correcting higher-order aberrations increases peak visual or optical performance, but results in a more rapid loss of performance away from the in-focus condition. Adaptive optics systems which incorporate a HartmanShack sensor into a phoropter could offer personalised correction with a broader range of focus.

DOF gain, by loss of 0.07 line in snellen scale in non-adaptive optics (AO) corrected vs AO corrected eye

stimuli has its lowest amplitude when the eye is focused at infinity but there is considerable variation among individuals.

During accommodation, spherical aberration (Z40) tends to move to negative values, causing a lag in the defocus effect. When accommodation is relaxed the reverse occurs, enhancing the return to an unaccommodated state.

Coma-like aberrations (Z3-1, Z31) on

33

average change to positive values. Other dyamic changes in the optical system include saccadic ocular movements, artefacts introduced by blood flow or other metabolic process.

In summary, the eye is a dynamic system which scans the subject continuously in 3D and shows complex behaviour. Dynamics of ocular aberrations are random and as yet unpredictable. These dynamics introduce noise when estimating a wavefront and an average of several measurements should always be used to minimise these effects.

There are many other sources of error, none of them well understood.

I furthermore propose that the dictionary definition of emmetropia should be rewritten, based on the ancient meaning of the word and also on our evolving understanding of ocular dynamics and visual function.

The definition I suggest is as follows: “Emmetropia is the refractive state in a healthy eye in which any individual achieves the perfect visual function.”

Ioannis G Pallikaris: pallikaris@dunyagoz.com

DYNAMIC COMPONENTS

INDIA

Courtesy of Pablo Artal PhD

When aiming for emmetropia it is also important to have regard for the dynamic aspects of vision which have a continual and variable impact on the eye’s degree of focus and aberration profile, and which also play an important role in an individual’s visual perception.

Optical dynamic components are mostly related to the stability and accuracy of the accommodative response. The fluctuation of accommodation in response to visual

VISIT OUR WEBSITE FOR INDIAN DOCTORS

www.eurotimesindia.org EUROTIMES | FEBRUARY 2016

2016

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RESIDENT’S DIARY

ON MY OWN

Leigh Spielberg MD says performing solo vitrectomy

tests body and mind

M

Courtesy of Eoin Coveney

y back was and, most importantly, 7. soaked in Mind. How would I ever perspiration. learn to pay attention to all Drenched, seven components, much really. The only less do it well? So I focused thing that stood even more. Besides my hands, between my wet forehead and a I concentrated on the five salty drop of sweat stinging my other components. eye was the surgical cap.

I paid attention to my feet: I had never sweated as below my right foot was the much in the operating room vitrectomy control pedal, which as today; this was the second works much like the pedal of time Koorosh Faridpooya, a phaco machine. Below my one of my mentors in left foot was the microscope’s vitreoretinal surgery, let me foot pedal, which unlike phaco perform a vitrectomy. surgery, is continually, actively During my first vitrectomy, following the motion of the eye Dr Faridpooya had gone easy to maintain visibility. on me, but this time was Besides my hands and feet I different. Dr Faridpooya is had to remember to look! This razor sharp, and he expects entails monitoring half a dozen his trainees to be sharp too. factors just to maintain a clear Despite the sweat, I felt like I view of the posterior segment had it all under control, but (microscope + posterior this was just wishful thinking – segment biome + cornea an illusion. + anterior segment + lens + I had seen Dr Faridpooya anterior vitreous), each of which perform about 100 procedures, can get cloudy. This particular so I knew in my mind’s eye patient was pseduophakic, so how it was all supposed to at least I didn’t have to worry happen. But doing it myself about lens touch and the nearwas a different story. instant cataract that can cause.

First of all, the vitreous cutter But I struggled to maintain an ... I knew in my mind’s eye how it was all was in my right hand. Was it overview of the fundus while supposed to happen. But doing it myself in the correct location? Were making sure not to cut into was a different story the motions properly directed the retina. and sufficiently fluid to avoid Then there’s the auditory generating traction on the component, which, like during vitreous base, which can induce retinal tears? Was I actually cutting cataract surgery, provides feedback about what the machine is any vitreous, or was I simply re-aspirating the infusion fluid? It didn’t doing. Lastly, the most important bit, there’s the thought process, seem like much was happening. which has to plan and execute the whole ordeal.

Secondly, the illumination was in my left hand, which my The intellectual component of VR surgery was the most consciousness seemed to have been neglecting. Instead of unexpected element, the one that surprised me the most. My tangentially illuminating the vitreous, like a lighthouse beam mentors are all so experienced that it always seemed as though in a fog, it was pointed straight down, needlessly illuminating they didn’t need to plan what they were doing, as though it was all the macula like a searchlight. I corrected its position and reflex, all automatic. Not so. immediately felt better about myself. But this nice feeling Unexpected things are happening all the time, and they need wouldn’t last long. to be dealt with immediately. The induction of a PVD can cause a retinal tear anywhere, which can, within just a few minutes, lead to a retinal detachment.

PAY ATTENTION! What to do? Laser now, so I don’t forget, or laser later, “What’s your cut rate?” asked Dr Faridpooya from somewhere after properly shaving the periphery? Should I laser the whole behind me, where he was monitoring my “progress” on the periphery, or just around the retinal tear? Should I use kenakort flat-screen on the wall. I didn’t dare take my eyes away from the to be sure the periphery is totally clean? Or should I trust my own microscope to check the cut rate on the vitrectomy machine’s own inexperienced judgment, and start peeling the ILM before the screen. Before I could admit not knowing, he answered his own crystalline lens gets cloudy and makes a peel too difficult? question. “You’re in vitreous shave mode at 5,000 cuts per minute Meanwhile, I was making progress and Dr Faridpooya was (cpm) instead of vitreous core mode at 3,000cpm. At this rate we’ll satisfied, for the moment. I was focused and the seven components be here all day and night. Pay attention!” were all under control. I was in shave mode, indenting the periphery There were so many things that needed attention: 1. Right and trimming the vitreous base at 5,000cpm. So far so good! hand, 2. Left hand, 3. Right foot, 4. Left foot, 5. Eye, 6. Ears, Dr Faridpooya was satisfied for the moment.

EUROTIMES | FEBRUARY 2016

35

New Orleans 2016 Save the Date

Friday, May 6 – Monday, May 9, 2016 Make the most of your time at the ASCRS•ASOA Symposium & Congress and attend our EyeWorld multi-supported CME, independent education, and Corporate Events. They are a great opportunity to network with your colleagues while learning tips and techniques from the experts.

Among the topics to be covered in these AMA PRA Category 1 CreditsTM designated sessions are: • A discussion on recent developments in anti-inflammatory therapeutic treatments • Updates on diagnosing and treating the ocular surface, including dry eye disease and meibomian gland disease • New developments in glaucoma medical and surgical treatment options • New considerations and continuing discussions regarding laser-assisted cataract refractive surgery • Maximizing presbyopia-correcting outcomes • Successfully integrating toric IOLs and improving results and patient satisfaction • Mastering phaco dynamics, fluidics, power, and nuclear disassembly techniques • Advanced surgical technologies and techniques for the young physician

Registration opens January 2016 These non-CME, ASCRS-authorized educational programs will provide timely and important information on: • Options and considerations in the use of premium IOLs • Advances in technologies, techniques, and outcomes in laser vision correction surgery • An interactive discussion on the applications of femtosecond and excimer lasers for ophthalmic surgery

EyeWorld Corporate Events are directly developed by industry and hosted by EyeWorld. These non-CME meetings provide valuable information on new products, procedures, and applications of existing products. Included among the topics discussed in these sessions are: • • • • • • •

Live surgery New developments in surgical instrumentation Growing the overall size of the premium IOL market Considerations in the selection of a premium IOL New developments in laser vision correction Advanced IOL technology Discussion of technological advances and breakthroughs in cataract surgery • Update on crosslinking • Advances in diagnostics and imaging equipment

www.EyeWorld.org

Topics are subject to change.

ESCRS NEWS

© Orbis/ClareThomas

ESCRS

NEWS

SUPPORTING ORBIS The ESCRS is supporting a new Orbis initiative to strengthen a network of medical schools and training across six countries in East Africa.

This enterprise will address the gaps currently felt across eye healthcare systems in the region and look at ways to build an African-owned leadership network of skilled ophthalmic trainers.

This group will be able to improve training opportunities for medical professionals within their own countries, thus increasing the number of highly trained eye care specialists.

This initiative is part of the ongoing ESCRS support for Orbis and Oxfam. Details of the Oxfam project will be announced in the next edition of ESCRS News.

ESCRS LAUNCHES NEW LOGO "There is nothing permanent except change."

– Heraclitus of Greece, circa 470BC The ESCRS has a new logo which is now being displayed on all ESCRS literature, conference signage and on our website.

So why the new look?

At the ESCRS, evolution is at our core. The evolution of surgical procedures and treatments is the direct result of research and of ophthalmologists teaching and learning from each other.

Our identity must reflect our changing world and the global membership

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that we represent. We have thought about our society and what it means to you, our members and ophthalmologists who attend our conferences.

We believe our new logo will reflect our identity and the evolution of the ESCRS in the coming years.

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EUROTIMES | FEBRUARY 2016

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ESASO

RETINA ACADEMY 16th ESASO Retina Academy, Estoril, Portugal, 23-25 June 2016

R

egistration is now open for the 16th ESASO Retina Academy to be held in Estoril, Portugal, from 23-25 June 2016 at the Estoril Congress Center. The Congress Center has received the “Excellence in Innovation and Quality Architecture Prize” for its highly advanced building design and technical facilities. The ESASO Retina Academy promotes exchange of the latest advancements in ophthalmological equipment, diagnosis and treatment.

The ESASO Retina Academy is not only renowned for its outstanding faculty but also for its attractive, in part innovative, session formats that allow an optimised learning experience. This year’s innovations include an eye imaging workshop that will provide participants with the skills to effectively utilise various state-of-the art imaging devices and interpret the diagnostic medical images.

Among the topics covered are VMA/VMT/MH, AMD, DME, RVO, PM, retinal non-perfusion, OCT techniques development, retinal pharmacology, geographic atrophy, central serous chorioretinopathy, uveitis, dystrophy, rehabilitation, and artificial vision.

Highlights of the conference include two Lectio Magistralis keynote lectures and eight plenary presentations on hot topics in retina science, diagnosis and treatment, as well as debates between experts. In addition, the Academy offers a platform for faculty and participants from around the globe to interact in engaging small master classes, in the wellappreciated “Retinamour” clinical case discussions and in informal conversations. Again, the pharmaceutical industry will present their clinical research pipeline.

Participants are invited to submit cases to be reviewed and discussed in the interactive Retinamour sessions with internationally renowned experts. The deadline for case proposals is 24 March 2016.

The deadline for abstract submission is 10 March 2016.

Accepted abstracts will be displayed as posters and published in the scientific journal Ophthalmic Research. In addition, an expert panel will select the best abstracts and invite their authors to debate their studies in an oral rapid-fire presentation.

GRADUATION CEREMONY

www.esaso.org

Promising young eye doctors and scientists from all over the world are eligible for the “Young Ophthalmologist Award”.

The winners will be invited to attend the 17th ESASO Retina Academy in 2017 as special guests. Candidates must be no older than 40 years in 2016. The Scientific Committee will select the winners from the accepted abstracts.

As another annual tradition, the conference will host a graduation ceremony to honour the successful students who have completed the requirements of the ESASO fellowship programme and the ESASO graduation scheme.

The XOVA Excellence in Ophthalmology Awards honour and support extraordinary humanitarian eye care projects in developing countries. The programme is sponsored by Novartis Corporation. The winners will present their initiatives.

For further details visit: www.esaso.org

EUROTIMES | FEBRUARY 2016

JCRS

39

JCRS HIGHLIGHTS

VOL: 41 ISSUE: 11 MONTH: NOVEMBER 2015

CATARACT SURGERY AFTER REFRACTIVE SURGERY INCREASING The number of patients presenting for cataract surgery who have previously undergone corneal refractive surgery has been increasing steadily. These patients tend to be younger and are at increased risk of worse postoperative corrected distance visual acuity (CDVA), a new study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) database indicates. The review of 807,220 cataract cases reported over a five-year period showed a rate of 0.15 per cent of patients who had undergone previous corneal refractive surgery, with the rate increasing steadily. Postoperative CDVA was worse than preoperative CDVA in four per cent of corneal refractive patients, versus 1.5 per cent of non-refractive patients (P < .001). S Manning et al, JCRS, “Cataract surgery outcomes in corneal refractive surgery eyes: Study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery”, Volume 41, Issue 11, 2358-2365.

ENDO The real ARGON experience

TABLET APP FOR GLARE TESTING The Aston Halometer, a computer tablet based software app, provides a sensitive, repeatable way of quantifying a patientrecognised form of disability glare in multiple orientations, report British investigators. They evaluated the tool in a prospective study, which positioned 20 patients two meters from an iPad screen in a dark room, with the iPad controlled from an iPhone via Bluetooth.

The halometer comprises a bright light-emitting-diode (LED) glare source in the centre of the tablet. Letters subtending 0.21° were moved centrifugally from the LED in 0.05 degree steps, in eight orientations separated by 45 degrees for each of four contrast levels. Bangerter occlusion foils were inserted in front of the right eye to simulate monocular glare conditions. Intraobserver and interobserver repeatability of the Aston Halometer was good and similar to the C-Quant straylight meter. The researchers believe this test could add objectivity to subjectively reported discomfort glare. PJ Buckhurst et al, JCRS, “Tablet App halometer for the assessment of dysphotopsia”, Volume 41, Issue 11, 2424-2429.

m 14 n LIGHT 5 h t eleng N LASER Wav REE EG PUR

TORIC PHAKIC LENS IN PAEDIATRIC PATIENTS The toric phakic Visian ICL offers a safe and effective treatment option for refractory amblyopia due to anisometropic hyperopia or myopia in children who are non-compliant with conventional therapy, a new report suggests. A retrospective review found a total of 11 eyes (nine myopic, two hyperopic) of 11 patients aged five to 15 years. Six of the nine myopic eyes received spherical ICLs and three received toric ICLs. Both hyperopic eyes received spherical ICLs. The mean cycloplegic refractive spherical equivalent improved in both myopic and hyperopic cases at a follow-up of 16.8 months and 15 months, respectively. KE Emara et al, JCRS, “Implantation of spherical and toric copolymer phakic intraocular lens to manage amblyopia due to anisometropic hyperopia and myopia in paediatric patients”, Volume 41, Issue 11, 2458-2465.

d. were o p ry ES Batte RE CABL O NO M

. witch s t o o ote f ABLES Rem EC OR NO M

www.arclaser.com info@arclaser.com

Bessemerstr. 14 90411 Nuremberg Germany  +49 (0) 911 217 79 -0

THOMAS KOHNEN European editor of JCRS

Become a member of ESCRS to receive a copy of EuroTimes and JCRS journal

ESCRS EuroTimes_2016_halfPage.indd 1

EUROTIMES | FEBRUARY 2016

23.12.2015 12:23:15

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INDUSTRY NEWS

NEWS IN BRIEF POSITIVE FISCAL YEAR Carl Zeiss Meditec AG has reported a positive fiscal year.

Revenue passed the billion mark in the fiscal year 2014/15, with a 14 per cent increase to €1,040 million, according to Dr Ludwin Monz the company.

Adjusted for currency effects, this equates to growth of around eight per cent over the previous year. Earnings before interest and taxes (EBIT) increased by eight per cent, to €130.6 million (previous year: € 120.7 million).

“A strong fourth quarter and tailwind from the exchange rates of major currencies supported the good operating result,” said Dr Ludwin Monz, President and CEO of Carl Zeiss Meditec AG.

INDUSTRY

NEWS

ANTERIOR CHAMBER ANGLE NIDEK has launched the Anterior Chamber Angle (ACA) mode for the TONOPACHYTM NT-530P. “The Anterior Chamber Angle mode is a new feature included in the TONOPACHYTM NT-530P, the unique model combining Non Contact Tonometer and Pachymeter in one unit,” said a company spokesman.

The ACA mode allows the operator to capture an image of the anterior chamber angle with the Scheimpflug image. Along with the intraocular pressure, the visual observation of the anterior chamber angle further assists in the assessment of glaucoma. www.nidek.com

NEW WEBSITE LAUNCHED

Rainer Kirchhübel, CEO, Oculus

BEHIND THE SCENES The OCULUS company history film, telling the story of the company from 1895 to the present day, has been newly revised and is now available on the OCULUS website.

“Some 280 employees work in the areas of research and development, production, administration and sales at company headquarters in the Hessian city of Wetzlar (Germany),” said a company spokeswoman.

“OCULUS employees who speak to visitors on

EUROTIMES | FEBRUARY 2016

factory tours often receive looks of incredulity when they talk about the wide range of manufacturing activity at the Wetzlar-based workshop, production and assembly facilities – much of which involves handcraft,” she said.

The video includes a section called “We are OCULUS – Have a glimpse behind the scenes”, where viewers can get a personal tour of the factory, meet some of its employees and learn about some of its work processes. www.oculus.de/en/fromidea-to-product

Quantel Medical has launched a new website to inform doctors about the benefits of using yellow wavelength light during surgeries.

“The website will serve as a resource for interested ophthalmic professionals to learn more about Quantel Medical’s proprietary 577-nm MicroPulse® laser therapy, specifically about its applications in treating diabetic macular oedema (DME) and central serous chorioretinopathy (CSC),” said a company spokeswoman. www.retina-yellowlaser-therapy.com

www.zeiss.com

DIABETIC MACULAR OEDEMA Allegro Ophthalmics has announced completion of enrollment in its DEL MAR Phase 2b trial that is evaluating the safety and efficacy of Luminate® (ALG1001) in patients with diabetic macular oedema (DME).

The company expects to report topline data by the third quarter of 2016.

“Completing the last patient enrolment in the DEL MAR trial on schedule represents another significant clinical development milestone for this drug candidate, and moves us a step closer to potentially bringing this new category of treatment forward to help DME patients,” said Vicken Karageozian MD, Chief Technical Officer, Allegro Ophthalmics, LLC. www.allegroeye.com

WE WANT YOUR NEWS

If you want your company news considered for inclusion in this section, send your press releases and high resolution images to Colin Kerr, Executive Editor, EuroTimes.

Email: colin@eurotimes.org

OPHTHALMOLOGICA

OPHTHALMOLOGICA VOL: 235 ISSUE: 1

ic atr s i d Pae smu

SCLERAL BUCKLE BETTER THAN VITRECTOMY FOR PRESERVING VISUAL FIELD In eyes with primary rhegmatogenous retinal detachment (RRD), the visual function of areas unaffected by the condition is more impaired after pars plana vitrectomy (PPV) than it is after scleral buckle reattachment surgery, according to the results of a prospective, comparative interventional study. It showed that, in 50 eyes with RRD, the postoperative visual field total deviation values for the preoperatively un-detached areas of the retina were significantly better in 25 eyes treated with scleral buckle than in 25 eyes treated with PPV. The authors postulate that vitrectomy may be the more traumatising technique because of the additional measures it can involve, such as fluid-air exchange or gas injection. C Koutsandrea et al, “Scleral Buckling versus Vitrectomy for Retinal Detachment Repair: Comparison of Visual Fields and Nerve Fiber Layer Thickness”, Ophthalmologica 2016; Volume 235, Issue 1 (DOI: 10.1159/000439443).

RANIBIZUMAB EFFECTIVE IN HIGH-RISK PDR Intravitreal ranibizumab (IVR), alone or in combination with panretinal photocoagulation (PRP), is effective in the treatment of high-risk proliferative diabetic retinopathy (PDR) without vitreoretinal traction, according to the results of a multicentre randomised trial. The study involved 35 high-risk PDR patients and showed that there was a complete regression of disc neovascularisation in 44.4 per cent of eyes treated with PRP plus IVR, 37.5 per cent of eyes treated with IVR alone, and 30.8 per cent of eyes treated with PRP alone. The complete regression rates for new vessels elsewhere were 100 per cent, 75 per cent and 69.2 per cent, respectively. Furthermore, during the oneyear duration of treatment, there was no need for laser rescue treatment in IVR-treated eyes. J Figueira et al, “Ranibizumab for High-Risk Proliferative Diabetic Retinopathy: An Exploratory Randomized Controlled Trial”, Ophthalmologica 2016; Volume 235, Issue 1 (DOI: 10.1159/000442026).

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Bella Center, Copenhagen, Denmark Preceding the XXXIV Congress of the ESCRS 10 – 14 September 2016

CLOSING IN ON GENES FOR HIGH MYOPIA A case-control study has identified three loci of genetic variants that render individuals among China’s Han population more susceptible to developing high myopia. The loci, ZC3H11B, RSPO1 and GJD2, were among five loci identified in a previous genome-wide association study as being involved in the development of long axial length. The study’s authors genotyped five single nucleotide polymorphisms in 296 unrelated highly myopic individuals and 300 matched emmetropic controls by the SNaPshot method. They compared distribution of genotypes in the cases and controls in codominant, dominant, and recessive genetic models, using SNPStats online software. Li Y et al, “Association between Ocular Axial Length-Related Genes and High Myopia in a Han Chinese Population”, Ophthalmologica 2016; Volume 235, Issue 1 (DOI: 10.1159/000439446).

www.wspos.org

SEBASTIAN WOLF Editor of Ophthalmologica The peer-reviewed journal of EURETINA

EUROTIMES | FEBRUARY 2016

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42

REVIEW

HANDLE WITH CARE Everything you ever wanted to know about epinucleus and cortex aspiration.

Dr Soosan Jacob reports

E

pinucleus and cortex removal is an integral part of cataract surgery, and unless done properly and carefully can lead to a posterior capsular rent in this last stage of surgery. A good cortical cleaving hydrodissection is critical for proper management of cortex. Hydrodelineation allows nucleus emulsification to be performed within a safe epinuclear shell which is then removed separately.

EPINUCEUS REMOVAL The epinucleus is bowl-shaped and is removed in toto. The amount of epinucleus depends on the density of cataract and the depth of hydrodelineation. The softer the nucleus and the deeper the plane of hydrodelineation, the thicker the epinuclear shell. Unlike cortex which is stripped as sheets, the epinucleus breaks off in chunks.

Once the nucleus is removed, a loosened and free epinuclear bowl may be caught with the phaco probe in low vacuum and zero power, gently carouselled out into the anterior chamber (AC) and aspirated.

Using high vacuum can result in break of occlusion and aspiration of small chunks of the epinucleus. If repeated at multiple points, this can convert the bowl into a plate and therefore should be avoided.

Epinucleus may also be visco-prolapsed and aspirated. Gentle but continuous injection of viscoelastic under the epinuclear bowl while gently depressing the posterior lip of the incision often allows the epinucleus to be prolapsed into the AC. If difficulty is still experienced, the irrigation/aspiration (I/A) probe may be used to remove the epinuclear shell.

This is done by gently tugging on the peripheral cortex all around using aspiration, which results in loosening of the epinucleus from all sides. Once freed and brought to the centre, it may be EUROTIMES | FEBRUARY 2016

aspirated with the I/A probe using high vacuum (300-500 mmHg) with aspiration port facing up. In case of difficulty, the I/A probe may be nudged under the loosened and displaced epinuclear shell with aspiration port facing up.

CORTEX ASPIRATION Bimanual I/A: This requires the construction of either one additional port 180 degrees away from the side port or two completely new ports 180 degrees apart.

The main port is not used as it does not give a watertight fit around the bimanual instruments. It has the advantages of offering excellent closed chamber stability at all times, as well as being able to switch irrigation and aspiration between hands to gain 360-degree access to the capsular bag.

Coaxial I/A: The coaxial probe may also be used very efficiently, however sub-incisional cortex may be more challenging in this case. I/A probes may be made entirely of steel or may have a silicone sleeve which helps prevent wound leak. The irrigation ports must be placed perpendicular to the aspiration port and the sleeve should be adjusted to get the right amount of tip exposed. Straight, 45-degree or 90-degree tips may be used.

After complete tip occlusion, cortex is stripped inwards while simultaneously increasing vacuum

With the aspiration port facing up, peripheral cortical strands are engaged with low vacuum. Once the tip is completely occluded, vacuum is gently increased and the tip is moved towards the centre in order to strip the cortex as a sheet. The same is repeated at multiple points. Increasing vacuum while holding small wispy strands of cortex that do not completely occlude the tip does not prove effective, as occlusion of the tip needs to be achieved before increasing vacuum.

The port should never be facing down while aspirating cortex in order to avoid a posterior capsular rent. Blind manoeuvres should be avoided. With conventional cataract surgery, cortical strands always extend beyond the anterior capsule margin and are easy to engage, however in femtosecond cataract surgery, the laser also cuts the superficial cortex in line with the rhexis and necessitates having to go under the anterior capsule with the I/A tip in order to engage the cortex.

SUB-INCISIONAL CORTEX With coaxial I/A, sub-incisional cortex may either be tackled first while the remaining cortex holds the bag open or may be left for last. The sleeve may need to be drawn

Complete cortex aspiration decreases complications such as inflammation, posterior capsular opacification and IOL decentration

REVIEW back slightly to get better visibility and access to sub-incisional cortex, however an excessively drawn back sleeve may cause irrigation to come out of the main port while manoeuvring and this should be avoided.

Turning the aspiration port to either side helps to engage the cortex, but care should be taken to avoid shallowing of the AC and inadvertent engagement of the posterior capsule. CapVac mode used for polishing the capsule is very effective for removing sub-incisional cortex and offers a greater margin of safety. The peripheral cortex under the anterior capsule or the cortical strand on the posterior capsule may be directly engaged on this mode.

In case difficulty is still experienced, bimanual I/A can be used to easily remove the cortex. A Symcoe cannula introduced from the opposite side also serves the purpose well. Stubborn and difficult to remove sub-incisional cortex may be tackled after intraocular lens (IOL) placement.

Dialling the IOL loosens the cortex. I/A may then be attempted with higher vacuum levels safely, as the IOL holds the posterior capsule down. The IOL is gently nudged towards the sub-incisional cortex with the left hand in order to push the posterior capsule away while aspirating with higher vacuum levels.

CAPSULE POLISHING The anterior and posterior capsule can be polished to decrease the incidence of

Sub-incisional cortex may be removed safely with bimanual or coaxial I/A

Capsular polishing mode helps in safe removal of sub-incisional cortex. The cortical sheet may be caught straight off the posterior capsule with capsular polish mode as seen in the image

posterior capsular opacification, as well as to remove any plaques and residual lens epithelial cells. This should not be done in case of subluxated or posterior polar cataracts or with a posterior capsular tear.

different techniques that can be adopted in case difficulty is experienced.

CONCLUSION To conclude, thorough and complete cortex aspiration must be aimed for as retained cortex can lead to inflammation, posterior capsular opacification, IOL decentration, and can promote capsular phimosis and cystoid macular oedema. Following basic principles of I/A allows easy management.

The surgeon should have knowledge of

Dr Soosan Jacob is Director and Chief of Dr Agarwalâ&#x20AC;&#x2122;s Refractive and Cornea Foundation at Dr Agarwalâ&#x20AC;&#x2122;s Eye Hospital, Chennai, India, and can be reached at: dr_soosanj@hotmail.com

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www.blinkmedical.com EUROTIMES | FEBRUARY 2016

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44

Milan

CALENDAR

MARCH

1st International Meeting Update on Optic Nerve Degeneration: a European Network

↙

18–19 March Milan, Italy www.jaka.it

LAST CALL

FEBRUARY 2016

Echography Teaching Services International Annual Course and Workshop on Diagnostic Ultrasound in Ophthalmology 1–5 February Naples, Italy www.echography.com

5–9 February Guadalajara, Mexico www.woc2016.org

MAY

Middle East Africa Council of Ophthalmology (MEACO) XIII International Congress 4–8 May Manama, Bahrain www.meaco.org

25–27 February Rimini, Italy www.sitrac.it

20th ESCRS Winter Meeting

NEW XXXth Meeting of the Club Jules Gonin

NEW 46th ECLSO Congress (European Contact Lens Society of Ophthalmologists)

1–3 July Crete, Greece www.ivo.gr/en/aegean-cornea/ meeting.html

23–25 September Zurich, Switzerland www.epos-focus.org

6–9 July Bordeaux, France www.clubjulesgonin.com

30 September–1 October Paris, France www.eclso.eu

OCTOBER

27–30 July Nusa Dua, Bali www.apacrs.org

The European Association for Vision and Eye Research (EVER) Congress 2016

SEPTEMBER

NEW CFSR (Club Francophone des Spécialistes de la Rétine) 8 May Paris, France www.cfsr-retine.com

18–21 May Milan, Italy www.congressisoi.com

JUNE

12th EGS Congress 19–22 June Prague, Czech Republic www.eugs.org

5–8 October Nice, France www.ever.be

16th EURETINA Congress 8–11 September Copenhagen, Denmark www.euretina.org

AAO 2016

15–18 October Chicago, USA www.aao.org

7th EuCornea Congress

14th SOI International Congress

CONTACT

42nd Annual EPOS Meeting

29th APACRS Annual Meeting

6–10 May New Orleans, USA www.ascrs.org

EYE

Aegean Cornea 2016

9–10 September Copenhagen, Denmark www.eucornea.org

XXXIV Congress of the ESCRS 10–14 September Copenhagen, Denmark www.escrs.org

↙

XX National Meeting of the Italian Cornea Transplant Society (S.I.Tra.C)

26–28 February Athens, Greece www.escrs.org

31 March–3 April Warsaw, Poland www.comtecmed.com/cophy/2016

ASCRS 2016

WOC 2016 World Ophthalmology Congress

SEPTEMBER

JULY

7th World Congress on Controversies in Ophthalmology

NEW 12th JOI (Journées d’Ophtalmologie Interactives) 23–24 September Toulouse, France www.joi-asso.fr

STUDIO INTERVIEWS with leading ophthalmologists EXCLUSIVE TO EUROTIMES! CURRENT ISSUES WITH STRABISMUS

Dr David Granet interviews Dr Lionel Kowal

Available at www.eurotimes.org/eyecontact and the EuroTimes App

NEW ORLEANS

MAY 6–10

ONE FOCUS. ONE VISION. “Best symposium to acquire and share up-to-date information on the latest developments in the field of anterior segment surgery” TOP REASONS TO ATTEND • More innovative lectures, case studies, and interactive panels • Crossover access for ASCRS and ASOA programs • 1300 sessions and post-meeting resources—films, posters, symposia, and papers • Roundtables and private consultations with experts • Daily networking events • 34th ASCRS Film Festival and reception • Programming for Young Eye Surgeons (YES) • Exhibit Hall entry for 3 days to meet more than 300 ophthalmic industry exhibitors

REGISTER TODAY TIER I DEADLINE THURSDAY, FEBRUARY 18

AnnualMeeting.ascrs.org

ADDITIONAL PROGRAMS T&N TECH TALKS (NEW EDUCATIONAL FORUM FOR TECHNICIANS & NURSES) ASOA WORKSHOPS ASCRS GLAUCOMA DAY CORNEA DAY

TECHNICIANS & NURSES PROGRAM MAY 7–9, 2016

NEW UNPRESERVED

ONCE DAILY

New horizons in treating severe keratitis in dry eye disease.

The first and only ciclosporin eye drops licensed in the UK. n Ikervis effectively delivers ciclosporin with once-daily dosing 1 n Reduces corneal damage, consistent with an improvement in patients’ disease severity 2 n Reduces ocular surface inflammation 3 Ikervis® is indicated for the treatment of severe keratitis in adult patients with dry eye disease, which has not improved despite treatment with tear substitutes.

Please refer to the product Summary of Product Characteristics for full details.

Product Name: IKERVIS® 1 mg/mL eye drops, emulsion. Composition: One ml of emulsion contains 1 mg of ciclosporin and 0.05mg cetalkonium chloride as an excipient. Please refer to the Summary of Product Characteristics (SmPC) for a full list of excipients. Indication: Treatment of severe keratitis in adult patients with dry eye disease, which has not improved despite treatment with tear substitutes. Dosage and administration: IKERVIS® treatment must be initiated by an ophthalmologist or a healthcare professional qualified in ophthalmology. The recommended dose is one drop of IKERVIS® once daily to be applied to the affected eye(s) at bedtime. Response to treatment should be reassessed at least every 6 months. To reduce systemic absorption, advise patients to use nasolacrimal occlusion and to close the eyelids for 2 minutes after instillation. If more than one topical ophthalmic product is used, 15 minutes should separate their administration. IKERVIS should be administered last. Contraindications: Hypersensitivity to any of the ingredients. Active or suspected ocular or peri-ocular infection. Warnings and Precautions: Use with caution in patients with a history of ocular herpes . Contact lenses: Patients wearing contact lenses have not been studied. Monitor carefully inpatients with severe keratitis . Contact lenses should be removed before instillation of the eye drops at bedtime and may be reinserted at wake-up time. Concomitant therapy: Use with caution in patients with glaucoma, especially in those receiving concomitant beta-blockers which are known to decrease tear secretion. Immune system effects: Medicinal products which affect the immune system, including ciclosporin, may affect host defences against infections and malignancies. Contains cetalkonium chloride which may cause eye irritation. Interactions with other medicinal products: Coadministration with eye-drops containing corticosteroids may potentiate effects on the immune system. Pregnancy and Breast Feeding: Not recommended in women of childbearing potential not using effective contraception or during pregnancy unless the potential benefit to the mother outweighs the potential risk to the foetus. Benefits of treatment must be weighed against the benefits of breast feeding. Driving and using machines: Moderate influence on the ability to drive and use machines. If blurred vision occurs on instillation, the patient should be advised to not drive or use machines until their vision has cleared. Undesirable Effects: Consult SmPC for full details. The most common adverse reactions in clinical studies were eye pain, eye irritation, lacrimation, ocular hyperaemia and eyelid erythema.

Patients receiving immunosuppressive therapies including ciclosporin, are at an increased risk of infections. Special Precautions for Storage: Do not freeze. After opening of the aluminium pouches, the single-dose containers should be kept in the pouches in order to protect from light and avoid evaporation. Discardany opened individual single-dose container with any remaining emulsion immediately after use. Package quantities and basic NHS cost: 30 x 0.3ml single-dose containers £72.00. Product Licence Holder: Santen Oy, Niittyhaankatu 20, 33720 Tampere, Finland (PL 16058/0012) (EU/1/15/990/001 & 002) Date of Authorisation: March 2015 Legal Category: POM Date of last revision of Prescribing Information: 07/07/2015 IKERVIS® is a registered trademark of Santen Pharmaceuticals Co., Ltd. Job code: STN 0617 IKV 00004b Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Santen UK Limited (Email medinfo@santen.co.uk or telephone: 0845 075 4863).

1 3

Lallemand F et al. J Drug Deliv 2012: 604204 2 SANSIKA study, Santen Data on File 0001 SANSIKA study, Santen Data on File 0002

Date of preparation: September 2015 Job code: STN 0717 IKV 00019f(eu)